Provider Demographics
NPI:1003116757
Name:FORSTBAUER, NANCY (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:FORSTBAUER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 ODELL LAKE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12167-2136
Mailing Address - Country:US
Mailing Address - Phone:607-652-5877
Mailing Address - Fax:
Practice Address - Street 1:15611 STATE HIGHWAY 23
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:NY
Practice Address - Zip Code:13750-8451
Practice Address - Country:US
Practice Address - Phone:607-278-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013207-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist