Provider Demographics
NPI:1396998324
Name:TEDESCO, TARA A (MA,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:A
Last Name:TEDESCO
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:A
Other - Last Name:VURCKIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,CCC-SLP
Mailing Address - Street 1:311 DEMOREST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3111
Mailing Address - Country:US
Mailing Address - Phone:718-448-1589
Mailing Address - Fax:
Practice Address - Street 1:311 DEMOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3111
Practice Address - Country:US
Practice Address - Phone:718-448-1589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58012294235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist