Provider Demographics
NPI:1962985069
Name:PONTOLILLO, KRISTEN MARIE
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:PONTOLILLO
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 1:98 SKELLY PL
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3730
Mailing Address - Country:US
Mailing Address - Phone:516-225-9131
Mailing Address - Fax:
Practice Address - Street 1:129A HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-2305
Practice Address - Country:US
Practice Address - Phone:516-742-5243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1261640181235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist