Mid-Island Speech Language Pathology, PLLC

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

108418 Issued in NY

Legal business name

MID-ISLAND SPEECH LANGUAGE PATHOLOGY, PLLC

Practice address

24 Donald Street
Holbrook, NY 11741

Phone

(631) 387-1926

NPI assigned

Jan 5, 2018

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Jaclyn Havlicek, MA, CCC-SLP

Title

Speech Pathologist, Owner

Phone

(631) 387-1926

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1515110400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1515110400000",
    "number": "1780191288",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "24 DONALD STREET",
            "city": "HOLBROOK",
            "state": "NY",
            "postal_code": "11741",
            "telephone_number": "631-387-1926"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "24 DONALD STREET",
            "city": "HOLBROOK",
            "state": "NY",
            "postal_code": "11741",
            "telephone_number": "631-387-1926"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MID-ISLAND SPEECH LANGUAGE PATHOLOGY, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-01-05",
        "last_updated": "2018-01-05",
        "status": "A",
        "authorized_official_last_name": "HAVLICEK",
        "authorized_official_first_name": "JACLYN",
        "authorized_official_title_or_position": "SPEECH PATHOLOGIST, OWNER",
        "authorized_official_telephone_number": "631-387-1926",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "MA, CCC-SLP"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Speech-Language Pathologist",
            "state": "NY",
            "license": "108418",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 5, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.