Provider Demographics
NPI:1871936260
Name:NYSARC SUFFOLK CHAPTER
Entity type:Organization
Organization Name:NYSARC SUFFOLK CHAPTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:TSHH
Authorized Official - Phone:631-218-4949
Mailing Address - Street 1:45 CROSSWAY E
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-1204
Mailing Address - Country:US
Mailing Address - Phone:631-218-4949
Mailing Address - Fax:631-567-3640
Practice Address - Street 1:45 CROSSWAY E
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1204
Practice Address - Country:US
Practice Address - Phone:631-218-4949
Practice Address - Fax:631-567-3640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service