Provider Demographics
NPI:1629599808
Name:KOVALENKO, LAURA (MS, CCC- SLP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:KOVALENKO
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 1:100 TILSON PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 TILSON PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305
Practice Address - Country:US
Practice Address - Phone:347-557-5319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028040235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist