Provider Demographics
NPI:1710249065
Name:TAVERAS, WIDNA (MA ED)
Entity Type:Individual
Prefix:
First Name:WIDNA
Middle Name:
Last Name:TAVERAS
Suffix:
Gender:F
Credentials:MA ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 PINE TREE ROAD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950
Mailing Address - Country:US
Mailing Address - Phone:646-296-9221
Mailing Address - Fax:
Practice Address - Street 1:181 PINE TREE ROAD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950
Practice Address - Country:US
Practice Address - Phone:646-296-9221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175241235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist