Basic Information
| Provider Information | |||||||||
| NPI: | 1386812550 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN NEW YORK SPEECH-LANGUAGE PATHOLOGY, OT, AND PT CONSULTANTS | ||||||||
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| OtherOrganizationName: | CLINICAL ASSOCIATES OF THE FINGER LAKES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 590 FISHERS STATION DR | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | VICTOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145649744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859247207 | ||||||||
| FaxNumber: | 5859247049 | ||||||||
| Practice Location | |||||||||
| Address1: | 590 FISHERS STATION DR | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | VICTOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145649744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859247207 | ||||||||
| FaxNumber: | 5859247049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2008 | ||||||||
| LastUpdateDate: | 05/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | LEITGEB | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5859247207 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.S., CCC-SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 002543-1 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 252Y00000X | 002543-1 | NY | N | Agencies | Early Intervention Provider Agency | 235Z00000X | 002543-1 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.