Provider Demographics
NPI:1447493176
Name:DEOLIVEIRA, ANISIO (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANISIO
Middle Name:
Last Name:DEOLIVEIRA
Suffix:
Gender:M
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 1:78 MAGAZINE ST
Mailing Address - Street 2:AP#2
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-3476
Mailing Address - Country:US
Mailing Address - Phone:917-770-3674
Mailing Address - Fax:
Practice Address - Street 1:2901 216TH ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2810
Practice Address - Country:US
Practice Address - Phone:718-281-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017335235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist