Provider Demographics
NPI:1659659910
Name:POLLAND, ELISSA (MS, CCC/SLP)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:POLLAND
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:
Other - Last Name:JACOBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC/SLP
Mailing Address - Street 1:966 GERRY AVE
Mailing Address - Street 2:
Mailing Address - City:LIDO BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-5217
Mailing Address - Country:US
Mailing Address - Phone:516-850-1348
Mailing Address - Fax:
Practice Address - Street 1:966 GERRY AVE
Practice Address - Street 2:
Practice Address - City:LIDO BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-5217
Practice Address - Country:US
Practice Address - Phone:516-850-1348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015148-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY015148-1OtherNEW YORK STATE EDUCATION DEPARTMENT DIVISION OF PROFESSIONAL LICENSING SERVICES