Provider Demographics
NPI:1780191288
Name:MID-ISLAND SPEECH LANGUAGE PATHOLOGY, PLLC
Entity Type:Organization
Organization Name:MID-ISLAND SPEECH LANGUAGE PATHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST, OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVLICEK
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:631-387-1926
Mailing Address - Street 1:24 DONALD STREET
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741
Mailing Address - Country:US
Mailing Address - Phone:631-387-1926
Mailing Address - Fax:
Practice Address - Street 1:24 DONALD STREET
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741
Practice Address - Country:US
Practice Address - Phone:631-387-1926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108418235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty