Provider First Line Business Practice Location Address: 
177 FORT WASHINGTON AVE
    Provider Second Line Business Practice Location Address: 
SPEECH PATHOLOGY DEPARTMENT
    Provider Business Practice Location Address City Name: 
NEW YORK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10032-3733
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-305-4958
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/10/2016