Provider Demographics
NPI:1578708855
Name:LAINE, TATIAANA
Entity Type:Individual
Prefix:
First Name:TATIAANA
Middle Name:
Last Name:LAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 BROADWAY
Mailing Address - Street 2:CCAA
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-2102
Mailing Address - Country:US
Mailing Address - Phone:212-567-3164
Mailing Address - Fax:
Practice Address - Street 1:4600 BROADWAY
Practice Address - Street 2:CCAA
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-2102
Practice Address - Country:US
Practice Address - Phone:212-567-3164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017882-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist