Provider Demographics
NPI:1396359097
Name:MINTZ, MARLEY (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARLEY
Middle Name:
Last Name:MINTZ
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3352 62ND ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2282
Mailing Address - Country:US
Mailing Address - Phone:718-429-3141
Mailing Address - Fax:
Practice Address - Street 1:3352 62ND ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-2282
Practice Address - Country:US
Practice Address - Phone:718-429-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030029235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist