Provider Demographics
NPI:1780034702
Name:ROEDER, DANIELLE (MS SLP-CCC, TSSLD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:ROEDER
Suffix:
Gender:F
Credentials:MS SLP-CCC, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 E 91ST ST
Mailing Address - Street 2:P138M@114
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:331 E 91ST ST
Practice Address - Street 2:P138M@114
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-5937
Practice Address - Country:US
Practice Address - Phone:845-641-1693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025766174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist