Provider Demographics
NPI:1528401551
Name:VARDOULIAS, ATHANASIOS (MA, CCC-SLP, TSSLD)
Entity Type:Individual
Prefix:
First Name:ATHANASIOS
Middle Name:
Last Name:VARDOULIAS
Suffix:
Gender:M
Credentials:MA, CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 CENTRAL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-5446
Mailing Address - Country:US
Mailing Address - Phone:516-603-1262
Mailing Address - Fax:
Practice Address - Street 1:73 CENTRAL ST APT 3
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5446
Practice Address - Country:US
Practice Address - Phone:516-603-1262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019880235Z00000X
MA9044235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist