Provider Demographics
NPI:1558697367
Name:DESIMONE, MICHELE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:DESIMONE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1148
Mailing Address - Country:US
Mailing Address - Phone:718-979-5678
Mailing Address - Fax:
Practice Address - Street 1:8 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-1148
Practice Address - Country:US
Practice Address - Phone:718-979-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist