Provider Demographics
NPI:1265809081
Name:ANTONELLIS, SUSAN A (AUD CCC-A/F-AAA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:ANTONELLIS
Suffix:
Gender:F
Credentials:AUD CCC-A/F-AAA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:CLEMENTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 FROST MILL RD
Mailing Address - Street 2:
Mailing Address - City:MILL NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11765-1102
Mailing Address - Country:US
Mailing Address - Phone:516-628-4268
Mailing Address - Fax:516-922-3889
Practice Address - Street 1:40 FROST MILL RD
Practice Address - Street 2:
Practice Address - City:MILL NECK
Practice Address - State:NY
Practice Address - Zip Code:11765-1102
Practice Address - Country:US
Practice Address - Phone:516-628-4268
Practice Address - Fax:516-922-3889
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000801-1231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04484126Medicaid
NYA400150919Medicare PIN