Provider Demographics
NPI:1982304580
Name:OLIVERA, ELISSA JULIA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:JULIA
Last Name:OLIVERA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 N GARDINER DR
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-1418
Mailing Address - Country:US
Mailing Address - Phone:631-645-1628
Mailing Address - Fax:
Practice Address - Street 1:10 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3403
Practice Address - Country:US
Practice Address - Phone:631-645-1628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032812235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist