Provider Demographics
NPI:1851601918
Name:BALES, DEBRA KIM (MA, CCC, SLP)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:KIM
Last Name:BALES
Suffix:
Gender:F
Credentials:MA, CCC, SLP
Other - Prefix:MISS
Other - First Name:DEBRA
Other - Middle Name:KIM
Other - Last Name:NICOSIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1165 SALTAIRE WAY
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-3019
Mailing Address - Country:US
Mailing Address - Phone:631-298-7220
Mailing Address - Fax:631-298-7220
Practice Address - Street 1:1165 SALTAIRE WAY
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11952-3019
Practice Address - Country:US
Practice Address - Phone:631-298-7220
Practice Address - Fax:631-298-7220
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004530-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist