1023385895 NPI number — MS. CYNTHIA LYNN CERSOSIM MA, CCC/SLP

Table of content: DR. TOMMY LEE LOUISVILLE M.D. (NPI 1225139496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023385895 NPI number — MS. CYNTHIA LYNN CERSOSIM MA, CCC/SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CERSOSIM
Provider First Name:
CYNTHIA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA, CCC/SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023385895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1415 EAST THIRD AVE
Provider Second Line Business Mailing Address:
MARY G. CLARKSON ELEMENTARY SCHOOL
Provider Business Mailing Address City Name:
BAY SHORE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11706-4221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-968-1205
Provider Business Mailing Address Fax Number:
631-968-2461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 EAST THIRD AVE
Provider Second Line Business Practice Location Address:
MARY G. CLARKSON ELEMENTARY SCHOOL
Provider Business Practice Location Address City Name:
BAY SHORE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11706-4221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-968-1205
Provider Business Practice Location Address Fax Number:
631-968-2461
Provider Enumeration Date:
11/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  017749-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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