Provider Demographics
NPI:1841717709
Name:OCTOBER, SHILISHA T
Entity type:Individual
Prefix:
First Name:SHILISHA
Middle Name:T
Last Name:OCTOBER
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 1:419 W 129TH ST APT 27
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-2757
Mailing Address - Country:US
Mailing Address - Phone:917-470-6192
Mailing Address - Fax:
Practice Address - Street 1:351 W 18TH ST RM 301
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4402
Practice Address - Country:US
Practice Address - Phone:212-627-2812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026867235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist