Provider Demographics
NPI:1720475031
Name:KAKOULLIS, FAYE
Entity Type:Individual
Prefix:
First Name:FAYE
Middle Name:
Last Name:KAKOULLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17005 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1803
Mailing Address - Country:US
Mailing Address - Phone:646-530-0550
Mailing Address - Fax:
Practice Address - Street 1:585 STEWART AVENUE
Practice Address - Street 2:SUITE 310
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-627-3036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024616235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist