Provider Demographics
NPI:1306197173
Name:VACCALLUZZO, MARISA GLADYS (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:GLADYS
Last Name:VACCALLUZZO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7900 DECLARATION LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-3710
Mailing Address - Country:US
Mailing Address - Phone:301-469-4824
Mailing Address - Fax:
Practice Address - Street 1:9801 GEORGIA AVE STE 229
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-5276
Practice Address - Country:US
Practice Address - Phone:301-754-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC000514235Z00000X
MD06486235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist