Provider Demographics
NPI:1851438592
Name:VASILIADOU-THOMAS, THEODORA
Entity Type:Individual
Prefix:
First Name:THEODORA
Middle Name:
Last Name:VASILIADOU-THOMAS
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 1:2158 PINE ST
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-4114
Mailing Address - Country:US
Mailing Address - Phone:516-809-6802
Mailing Address - Fax:
Practice Address - Street 1:49 WIRELESS BLVD
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3935
Practice Address - Country:US
Practice Address - Phone:631-382-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011888-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist