Provider Demographics
NPI:1740957810
Name:FASANO, JEANINE MARIE (MA, CCC-SLP, TSSLD)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:MARIE
Last Name:FASANO
Suffix:
Gender:F
Credentials:MA, CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HILDRETH PL
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-3009
Mailing Address - Country:US
Mailing Address - Phone:914-346-0128
Mailing Address - Fax:
Practice Address - Street 1:77 N CENTRE AVE STE 215
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3923
Practice Address - Country:US
Practice Address - Phone:631-363-5794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 252Y00000X
NY032063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty