Provider Demographics
NPI:1407124647
Name:STALLONE, TARA LYN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYN
Last Name:STALLONE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 JEREMY COURT
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720
Mailing Address - Country:US
Mailing Address - Phone:631-241-2513
Mailing Address - Fax:
Practice Address - Street 1:7 JEREMY CT
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720
Practice Address - Country:US
Practice Address - Phone:631-241-2513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58 009471235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist