Provider Demographics
NPI:1720357916
Name:BLUMENTHAL, THERESA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BLUMENTHAL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:CASSANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-2225
Mailing Address - Country:US
Mailing Address - Phone:631-265-2085
Mailing Address - Fax:
Practice Address - Street 1:380 OLD TOWN ROAD
Practice Address - Street 2:
Practice Address - City:E. SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3499
Practice Address - Country:US
Practice Address - Phone:631-730-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018705235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist