Provider Demographics
NPI:1891214680
Name:ROTOLO, ELISSA S (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:S
Last Name:ROTOLO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 SOUNDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1709
Mailing Address - Country:US
Mailing Address - Phone:212-717-9916
Mailing Address - Fax:
Practice Address - Street 1:189 SOUNDVIEW DR
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-1709
Practice Address - Country:US
Practice Address - Phone:212-717-9916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NY015032-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist