Provider Demographics
NPI:1619226750
Name:ST.MARY'S HEALTHCARE SYSTEM FOR CHILDREN
Entity Type:Organization
Organization Name:ST.MARY'S HEALTHCARE SYSTEM FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGAUGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:LAVENDER-TABAR
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:917-670-6781
Mailing Address - Street 1:5 DAKOTA DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1107
Mailing Address - Country:US
Mailing Address - Phone:718-281-8579
Mailing Address - Fax:
Practice Address - Street 1:5 DAKOTA DR
Practice Address - Street 2:SUITE 200
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1107
Practice Address - Country:US
Practice Address - Phone:718-281-8579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021574302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization