Provider Demographics
NPI:1932472941
Name:NEOCLIS, KOSTAS (SCD)
Entity Type:Individual
Prefix:
First Name:KOSTAS
Middle Name:
Last Name:NEOCLIS
Suffix:
Gender:M
Credentials:SCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7247-6822
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19170-0001
Mailing Address - Country:US
Mailing Address - Phone:914-241-1050
Mailing Address - Fax:914-242-1516
Practice Address - Street 1:4770 SUNRISE HWY STE 106
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-2911
Practice Address - Country:US
Practice Address - Phone:516-261-9398
Practice Address - Fax:516-261-9399
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2019-11-13
Deactivation Date:2013-01-11
Deactivation Code:
Reactivation Date:2013-05-22
Provider Licenses
StateLicense IDTaxonomies
MI1601000605231H00000X
NY002493231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03686835Medicaid
NY03686835Medicaid