Provider Demographics
NPI:1306317938
Name:PRAJEESH, SOUMYA (MASLP)
Entity type:Individual
Prefix:
First Name:SOUMYA
Middle Name:
Last Name:PRAJEESH
Suffix:
Gender:F
Credentials:MASLP
Other - Prefix:
Other - First Name:SOUMYA
Other - Middle Name:
Other - Last Name:G NAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASLP
Mailing Address - Street 1:3100 47TH AVE STE 2120
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3010
Mailing Address - Country:US
Mailing Address - Phone:718-593-4121
Mailing Address - Fax:718-268-2646
Practice Address - Street 1:3100 47TH AVE STE 2120
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3010
Practice Address - Country:US
Practice Address - Phone:718-593-4121
Practice Address - Fax:718-268-2646
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty