Provider Demographics
NPI:1306125067
Name:MAMEDOVA, YELENA (MS CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:YELENA
Middle Name:
Last Name:MAMEDOVA
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CLARK ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-6012
Mailing Address - Country:US
Mailing Address - Phone:617-733-4378
Mailing Address - Fax:
Practice Address - Street 1:13 CLARK ST
Practice Address - Street 2:UNIT 2
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-6012
Practice Address - Country:US
Practice Address - Phone:617-733-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5476235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist