Provider Demographics
NPI:1356891485
Name:COSTANTINO, NANCY BRIDGET (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:BRIDGET
Last Name:COSTANTINO
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 1:30 LINDA ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1732
Mailing Address - Country:US
Mailing Address - Phone:631-901-2420
Mailing Address - Fax:
Practice Address - Street 1:1500 WILLIAM FLOYD PKWY
Practice Address - Street 2:
Practice Address - City:EAST YAPHANK
Practice Address - State:NY
Practice Address - Zip Code:11967-1800
Practice Address - Country:US
Practice Address - Phone:631-901-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023049235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY235Z00000XMedicaid