Provider Demographics
NPI:1407563133
Name:AGBANG, MARYLEN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARYLEN
Middle Name:
Last Name:AGBANG
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 1:2614 TAHITI ISLE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-0998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:146 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02532-3902
Practice Address - Country:US
Practice Address - Phone:508-759-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22008037A235Z00000X
SD1129-SLP235Z00000X
WALL61400870235Z00000X
MA78579235Z00000X
NVSP-1992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist