Provider Demographics
NPI:1588035364
Name:ROLLER, MADELINE CONSTANCE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:CONSTANCE
Last Name:ROLLER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GOLD ST
Mailing Address - Street 2:APT 2402
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-4821
Mailing Address - Country:US
Mailing Address - Phone:251-282-0876
Mailing Address - Fax:
Practice Address - Street 1:227 W 29TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5210
Practice Address - Country:US
Practice Address - Phone:212-736-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024689235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist