Provider Demographics
NPI:1366074171
Name:SURAT, CHRISTINE ROSE
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ROSE
Last Name:SURAT
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 1:133 CLINTON B FISKE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2216
Mailing Address - Country:US
Mailing Address - Phone:718-702-6934
Mailing Address - Fax:
Practice Address - Street 1:155 TOMPKINS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2601
Practice Address - Country:US
Practice Address - Phone:718-273-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029544235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist