Provider Demographics
NPI:1043425408
Name:BARDWELL, MARIANNE K (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:K
Last Name:BARDWELL
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:MISS
Other - First Name:MARIANNE
Other - Middle Name:
Other - Last Name:KACHORSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19465 DEERFIELD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8446
Mailing Address - Country:US
Mailing Address - Phone:703-858-7620
Mailing Address - Fax:
Practice Address - Street 1:19465 DEERFIELD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8446
Practice Address - Country:US
Practice Address - Phone:703-858-7620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202001515235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4978196Medicaid
496524Medicare PIN