Provider Demographics
NPI:1326592098
Name:MCKEAN, MARIELLE VIRGINIA (MA, SLP)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:VIRGINIA
Last Name:MCKEAN
Suffix:
Gender:F
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NE NEFF RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6015
Mailing Address - Country:US
Mailing Address - Phone:541-382-4321
Mailing Address - Fax:
Practice Address - Street 1:2600 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6337
Practice Address - Country:US
Practice Address - Phone:541-706-6843
Practice Address - Fax:541-398-3444
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSLP.0000159235Z00000X
OR016215235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist