Provider Demographics
NPI:1497072219
Name:EASTERN SUFFOLK SPEECH AND LANGUAGE PATHOLOGY PC
Entity Type:Organization
Organization Name:EASTERN SUFFOLK SPEECH AND LANGUAGE PATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANGIFORTI
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:631-998-0368
Mailing Address - Street 1:4 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11977-1235
Mailing Address - Country:US
Mailing Address - Phone:631-998-0368
Mailing Address - Fax:631-878-1722
Practice Address - Street 1:4 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11977-1235
Practice Address - Country:US
Practice Address - Phone:631-998-0368
Practice Address - Fax:631-878-1722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008637-1235Z00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty