Provider Demographics
NPI:1871140046
Name:OTTAVIANO, LORA DANIELLE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:DANIELLE
Last Name:OTTAVIANO
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 CROFT LN
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4112
Mailing Address - Country:US
Mailing Address - Phone:631-672-8413
Mailing Address - Fax:
Practice Address - Street 1:72 CROFT LN
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4112
Practice Address - Country:US
Practice Address - Phone:631-672-8413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030292235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program