Provider Demographics
NPI:1992855613
Name:MAGNIFICO, ELISHA (SLP)
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:MAGNIFICO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:ELISHA
Other - Middle Name:
Other - Last Name:MAGNIFICO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA/CCC-SLP
Mailing Address - Street 1:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-0071
Mailing Address - Country:US
Mailing Address - Phone:603-924-7722
Mailing Address - Fax:
Practice Address - Street 1:70 MAIN STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1238
Practice Address - Country:US
Practice Address - Phone:603-924-7722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1111235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH99560056Medicaid
NH3074050Medicaid
NH561822OtherAETNA
NH66Y011091NH01OtherANTHEM BCBS
NH761242OtherTUFTS
NH272746OtherCIGNA
NH020377315OtherCOMMON TAX ID
NH626514OtherHARVARD PILGRIM