Provider Demographics
NPI:1366813180
Name:NICOSIA, REBECCA ANNE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:NICOSIA
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 1:707 STONER TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:FONDA
Mailing Address - State:NY
Mailing Address - Zip Code:12068-5014
Mailing Address - Country:US
Mailing Address - Phone:518-441-0680
Mailing Address - Fax:
Practice Address - Street 1:63 EVELYN AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1104
Practice Address - Country:US
Practice Address - Phone:518-736-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58 023435235Z00000X
NY023435235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist