Provider Demographics
NPI:1043464969
Name:TABOLT-PITTS, MAELEAH RUTH (MS-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MAELEAH
Middle Name:RUTH
Last Name:TABOLT-PITTS
Suffix:
Gender:F
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16783 IVES STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5312
Mailing Address - Country:US
Mailing Address - Phone:315-778-5377
Mailing Address - Fax:
Practice Address - Street 1:3375 DOUGLAS STREET
Practice Address - Street 2:
Practice Address - City:PORT LEYDEN
Practice Address - State:NY
Practice Address - Zip Code:13433
Practice Address - Country:US
Practice Address - Phone:315-513-4027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017771-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist