Provider Demographics
NPI:1194268219
Name:LOMBARDI, ETHAN M (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:M
Last Name:LOMBARDI
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 KENILWORTH PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-2328
Mailing Address - Country:US
Mailing Address - Phone:917-379-4196
Mailing Address - Fax:
Practice Address - Street 1:1023 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3806
Practice Address - Country:US
Practice Address - Phone:718-856-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024555-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist