Provider Demographics
NPI:1396828398
Name:MCCANNELL, JODY (SLP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:MCCANNELL
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 1:248 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1519
Mailing Address - Country:US
Mailing Address - Phone:207-989-2034
Mailing Address - Fax:207-989-5971
Practice Address - Street 1:248 STATE ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1519
Practice Address - Country:US
Practice Address - Phone:207-989-2034
Practice Address - Fax:207-989-5971
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEST1658235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist