Provider Demographics
NPI:1467692251
Name:BOONYATHITISUK, PISAMAI (MACCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:PISAMAI
Middle Name:
Last Name:BOONYATHITISUK
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13063 ZARBIS DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-9091
Mailing Address - Country:US
Mailing Address - Phone:917-324-3119
Mailing Address - Fax:
Practice Address - Street 1:13063 ZARBIS DR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-9091
Practice Address - Country:US
Practice Address - Phone:917-324-3119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014489235Z00000X
FLSA12735235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013291200Medicaid