Provider Demographics
NPI:1780964908
Name:ROMAN, KIM (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:54 GLADSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-3629
Mailing Address - Country:US
Mailing Address - Phone:631-365-5821
Mailing Address - Fax:
Practice Address - Street 1:54 GLADSTONE AVE
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-3629
Practice Address - Country:US
Practice Address - Phone:631-365-5821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist