Provider Demographics
NPI:1164565057
Name:NELSON, MAUREEN L (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2716
Mailing Address - Country:US
Mailing Address - Phone:631-863-2368
Mailing Address - Fax:631-863-2368
Practice Address - Street 1:29 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2716
Practice Address - Country:US
Practice Address - Phone:631-863-2368
Practice Address - Fax:631-863-2368
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01137235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist