Provider Demographics
NPI:1457763211
Name:MIAN, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MIAN
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 1:107 MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-4224
Mailing Address - Country:US
Mailing Address - Phone:516-521-7581
Mailing Address - Fax:
Practice Address - Street 1:20102 53RD AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364-1010
Practice Address - Country:US
Practice Address - Phone:516-521-7581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14030727235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY932221895OtherGHI