Provider Demographics
NPI:1487325361
Name:ABOVITZ, ILISSA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:ILISSA
Middle Name:
Last Name:ABOVITZ
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 MULBERRY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-2856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:295 BUCK RD STE 203
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-1748
Practice Address - Country:US
Practice Address - Phone:215-485-5018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00869700235Z00000X
PASL015695235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist