Provider Demographics
NPI:1831467687
Name:MIRTI, JACQUELINE M (MS ED, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:M
Last Name:MIRTI
Suffix:
Gender:F
Credentials:MS ED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 HERTEL AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-2303
Mailing Address - Country:US
Mailing Address - Phone:716-816-4150
Mailing Address - Fax:
Practice Address - Street 1:489 HERTEL AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-2303
Practice Address - Country:US
Practice Address - Phone:716-816-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008615-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist