Provider Demographics
NPI:1649580424
Name:EZZO, JOSEPHINE NICOLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:NICOLE
Last Name:EZZO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3554 AMHERST DRIVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793
Mailing Address - Country:US
Mailing Address - Phone:631-236-8046
Mailing Address - Fax:
Practice Address - Street 1:7002 54TH AVE
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-1745
Practice Address - Country:US
Practice Address - Phone:631-669-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020429-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist