Provider Demographics
NPI:1508300872
Name:ORTIZARCHIBALD, LAJUANA (CCC-SLP, TSSSH)
Entity Type:Individual
Prefix:
First Name:LAJUANA
Middle Name:
Last Name:ORTIZARCHIBALD
Suffix:
Gender:F
Credentials:CCC-SLP, TSSSH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2103
Mailing Address - Country:US
Mailing Address - Phone:347-417-2274
Mailing Address - Fax:
Practice Address - Street 1:780 POST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1927
Practice Address - Country:US
Practice Address - Phone:718-442-3860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012075235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist