Provider Demographics
NPI:1932798592
Name:LIFESPAN SPEECH AND SWALLOWING SERVICES
Entity Type:Organization
Organization Name:LIFESPAN SPEECH AND SWALLOWING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:DIRUZZO
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-552-0406
Mailing Address - Street 1:4820 W TAFT RD STE 202
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-2806
Mailing Address - Country:US
Mailing Address - Phone:315-552-0406
Mailing Address - Fax:315-634-6230
Practice Address - Street 1:4820 W TAFT RD STE 202
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088
Practice Address - Country:US
Practice Address - Phone:315-552-0406
Practice Address - Fax:315-634-6230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06039550Medicaid