Provider Demographics
NPI:1528330370
Name:MANIKAKIS, POLLY (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:POLLY
Middle Name:
Last Name:MANIKAKIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 OAK TREE CT
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1419
Mailing Address - Country:US
Mailing Address - Phone:718-825-4554
Mailing Address - Fax:
Practice Address - Street 1:240-45 66TH AVENUE
Practice Address - Street 2:
Practice Address - City:DOUGLASTON
Practice Address - State:NY
Practice Address - Zip Code:11362
Practice Address - Country:US
Practice Address - Phone:718-825-4554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021833235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03799497Medicaid