Provider Demographics
NPI:1043611619
Name:MISHRA, AVINASH (PHD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AVINASH
Middle Name:
Last Name:MISHRA
Suffix:
Gender:M
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15050 14TH RD
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-2609
Mailing Address - Country:US
Mailing Address - Phone:718-767-0071
Mailing Address - Fax:718-767-0086
Practice Address - Street 1:15050 14TH RD
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-2609
Practice Address - Country:US
Practice Address - Phone:718-767-0071
Practice Address - Fax:718-767-0086
Is Sole Proprietor?:No
Enumeration Date:2014-09-14
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY025109235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program