Provider Demographics
NPI:1750698080
Name:MODRUSON, ANTONELLA
Entity type:Individual
Prefix:MRS
First Name:ANTONELLA
Middle Name:
Last Name:MODRUSON
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 1:26 HASTINGS DR
Mailing Address - Street 2:
Mailing Address - City:FORT SALONGA
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2509
Mailing Address - Country:US
Mailing Address - Phone:631-239-1767
Mailing Address - Fax:
Practice Address - Street 1:144 COVERT AVE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-1138
Practice Address - Country:US
Practice Address - Phone:516-326-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58 015880235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist