Provider Demographics
NPI:1891179511
Name:COLACICCO, LAURA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:COLACICCO
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BIRCH PARKWAY
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1204
Mailing Address - Country:US
Mailing Address - Phone:973-729-6433
Mailing Address - Fax:
Practice Address - Street 1:1 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1205
Practice Address - Country:US
Practice Address - Phone:973-383-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00177600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist