Provider Demographics
NPI:1295987394
Name:SMIALEK, JOHANNA (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:
Last Name:SMIALEK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CORLISS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:NY
Mailing Address - Zip Code:12834-1004
Mailing Address - Country:US
Mailing Address - Phone:518-692-7153
Mailing Address - Fax:
Practice Address - Street 1:14 CORLISS AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:NY
Practice Address - Zip Code:12834-1004
Practice Address - Country:US
Practice Address - Phone:518-692-7153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010904235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03642239Medicaid