Provider Demographics
NPI:1790054906
Name:ISMAIL, DIMA
Entity Type:Individual
Prefix:
First Name:DIMA
Middle Name:
Last Name:ISMAIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 78TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3714
Mailing Address - Country:US
Mailing Address - Phone:718-506-6061
Mailing Address - Fax:
Practice Address - Street 1:1651 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5849
Practice Address - Country:US
Practice Address - Phone:718-998-1415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14056205235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist