Provider Demographics
NPI:1053623280
Name:TESORO, GINA (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:
Last Name:TESORO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 GLADWIN ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1984
Mailing Address - Country:US
Mailing Address - Phone:917-538-1374
Mailing Address - Fax:
Practice Address - Street 1:905 ANNADALE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-4010
Practice Address - Country:US
Practice Address - Phone:718-984-5826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017716-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist