Provider Demographics
NPI:1063888303
Name:DE FALCO, TRISTA
Entity type:Individual
Prefix:MISS
First Name:TRISTA
Middle Name:
Last Name:DE FALCO
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 1:8520 210TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-1312
Mailing Address - Country:US
Mailing Address - Phone:347-538-2181
Mailing Address - Fax:
Practice Address - Street 1:3636 33RD ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-2329
Practice Address - Country:US
Practice Address - Phone:212-589-1203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022081-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist