Provider Demographics
NPI:1952865131
Name:NEW YORK SPEECH AND LANGUAGE PLLC
Entity Type:Organization
Organization Name:NEW YORK SPEECH AND LANGUAGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER, SLP
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:302-841-7685
Mailing Address - Street 1:4505 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1625
Mailing Address - Country:US
Mailing Address - Phone:302-841-7685
Mailing Address - Fax:
Practice Address - Street 1:4505 BROADWAY
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-1625
Practice Address - Country:US
Practice Address - Phone:302-841-7685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05081663Medicaid