Provider Demographics
NPI:1457834442
Name:MIGNONE, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:MIGNONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 MARSEILLE PATH
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-1347
Mailing Address - Country:US
Mailing Address - Phone:631-873-5821
Mailing Address - Fax:
Practice Address - Street 1:280D ROUTE 130 STE 7
Practice Address - Street 2:
Practice Address - City:FORESTDALE
Practice Address - State:MA
Practice Address - Zip Code:02644-1140
Practice Address - Country:US
Practice Address - Phone:508-833-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77004-SP-SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist