| Doctor Name: | MRS. ANTONELLA MODRUSON |
| NPI Number: | 1750698080 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 58 015880 |
| Business Practice Address: | 144 Covert Ave Elmont, NY - 110031138 |
| Business Phone Number: | 5163265560 |
| Business Fax Number: | |
| Mailing Address: | 26 Hastings Dr, FORT SALONGA |
| State: | NY |
| Postal Code: | 117682509 |
| Phone Number: | 6312391767 |
| Fax Number: | |
| NPI Enumeration Date: | 09/08/2010 |
| NPI Last Update Date: | 09/08/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | 58 015880 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |