Provider Demographics
NPI:1487438644
Name:COLLAGUAZO, AIDA
Entity type:Individual
Prefix:
First Name:AIDA
Middle Name:
Last Name:COLLAGUAZO
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 1:4114 50TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4346
Mailing Address - Country:US
Mailing Address - Phone:347-417-6631
Mailing Address - Fax:
Practice Address - Street 1:10 AMBER LANE
Practice Address - Street 2:
Practice Address - City:OYSTER BAY
Practice Address - State:NY
Practice Address - Zip Code:11771-3115
Practice Address - Country:US
Practice Address - Phone:347-270-8850
Practice Address - Fax:888-634-3483
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist