Provider Demographics
NPI:1619443249
Name:FUNCTIONAL SPEECH PATHOLOGY, P.C.
Entity Type:Organization
Organization Name:FUNCTIONAL SPEECH PATHOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEENA
Authorized Official - Middle Name:VIJAY
Authorized Official - Last Name:BHOPALE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:917-747-4108
Mailing Address - Street 1:38 CLOVER LN
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-3304
Mailing Address - Country:US
Mailing Address - Phone:917-747-4108
Mailing Address - Fax:
Practice Address - Street 1:38 CLOVER LN
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-3304
Practice Address - Country:US
Practice Address - Phone:917-747-4108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03933075Medicaid