Basic Information
Provider Information
NPI: 1033558937
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DUSEL
FirstName: JACLYN
MiddleName:  
NamePrefix: MRS.
NameSuffix:  
Credential: MA, CCC/L-SLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: LEWANDOWSKI
OtherFirstName: JACLYN
OtherMiddleName:  
OtherNamePrefix: MRS.
OtherNameSuffix:  
OtherCredential: MA, CCC/L-SLP
OtherLastNameType: 1
Mailing Information
Address1: 4242 RIDGE LEA ROAD SUITE 2
Address2:  
City: AMHERST
State: NY
PostalCode: 14226
CountryCode: US
TelephoneNumber: 7168192400
FaxNumber:  
Practice Location
Address1: 4242 RIDGE LEA ROAD SUITE 2
Address2:  
City: AMHERST
State: NY
PostalCode: 14226
CountryCode: US
TelephoneNumber: 7168192400
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/24/2013
LastUpdateDate: 09/16/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000X NYY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 
235Z00000X022871-1NYN Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

ID Information
IDTypeStateIssuerDescription
0366259905NY MEDICAID


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