Provider Demographics
NPI:1760722318
Name:TALLERICO, PETER LOUIS III (SLP)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:LOUIS
Last Name:TALLERICO
Suffix:III
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 FARM ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-6698
Mailing Address - Country:US
Mailing Address - Phone:203-594-5200
Mailing Address - Fax:206-594-5412
Practice Address - Street 1:3 FARM RD
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-6698
Practice Address - Country:US
Practice Address - Phone:203-594-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003465235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist