Provider Demographics
NPI:1720378250
Name:LISS, DANIELLE REBECCA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:REBECCA
Last Name:LISS
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 1:1245 PARK AVE
Mailing Address - Street 2:APT. 8G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1735
Mailing Address - Country:US
Mailing Address - Phone:646-526-4699
Mailing Address - Fax:
Practice Address - Street 1:2778 BRUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-1934
Practice Address - Country:US
Practice Address - Phone:718-863-4925
Practice Address - Fax:718-863-5316
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58019534235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist