Provider Demographics
NPI:1699872424
Name:LAVALLEE, COLLEEN JESSICA (SLP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:JESSICA
Last Name:LAVALLEE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:JESSICA
Other - Last Name:HENZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:CENTER FOR DISABILITY SVCS, INC - LANGAN SCHOOL
Mailing Address - Street 2:314 SOUTH MANNING BLVD
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1708
Mailing Address - Country:US
Mailing Address - Phone:518-437-5639
Mailing Address - Fax:518-437-5736
Practice Address - Street 1:CENTER FOR DISABILITY SVCS, INC - LANGAN SCHOOL
Practice Address - Street 2:314 SOUTH MANNING BLVD
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1708
Practice Address - Country:US
Practice Address - Phone:518-437-5639
Practice Address - Fax:518-437-5736
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013662235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00013662Medicaid