Provider Demographics
NPI:1104946367
Name:KSYNIAK, LAURA ANN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:KSYNIAK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BERGEN DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1013
Mailing Address - Country:US
Mailing Address - Phone:973-837-1123
Mailing Address - Fax:
Practice Address - Street 1:89 BALDWIN TER
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-3654
Practice Address - Country:US
Practice Address - Phone:973-696-3928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00411700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist