Provider Demographics
NPI:1093247272
Name:MAILLOUX, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:MAILLOUX
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 1:225 MOUNTAIN VIEW RDG
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:VT
Mailing Address - Zip Code:05472-3124
Mailing Address - Country:US
Mailing Address - Phone:802-453-7445
Mailing Address - Fax:
Practice Address - Street 1:201 MARY HOGAN DR
Practice Address - Street 2:MARY HOGAN SCHOOL
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1328
Practice Address - Country:US
Practice Address - Phone:802-388-4421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT144.0115229235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist