Provider Demographics
NPI:1679388243
Name:KO, VIENNA
Entity type:Individual
Prefix:
First Name:VIENNA
Middle Name:
Last Name:KO
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 1:109 WILLOW AVE APT 15
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-7912
Mailing Address - Country:US
Mailing Address - Phone:617-515-1061
Mailing Address - Fax:
Practice Address - Street 1:109 WILLOW AVE APT 15
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-7912
Practice Address - Country:US
Practice Address - Phone:617-515-1061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032943235Z00000X
MASP-78603-SP-SL235Z00000X
NJ41YS01167700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist