Provider Demographics
NPI:1871102608
Name:ICKSTADT, ALLISON MARY
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:MARY
Last Name:ICKSTADT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 FORTUNE CT
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-2759
Mailing Address - Country:US
Mailing Address - Phone:516-221-1431
Mailing Address - Fax:
Practice Address - Street 1:1174 FORTUNE CT
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-2759
Practice Address - Country:US
Practice Address - Phone:516-221-1431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist