Provider Demographics
NPI:1437590684
Name:VIGNOLA-ROBESON, MARY CHRISTINE (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINE
Last Name:VIGNOLA-ROBESON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CHRISTINE
Other - Last Name:VIGNOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:655 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-8740
Mailing Address - Country:US
Mailing Address - Phone:570-842-9323
Mailing Address - Fax:570-842-9362
Practice Address - Street 1:542 BOULEVARD AVE
Practice Address - Street 2:
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1750
Practice Address - Country:US
Practice Address - Phone:570-489-5010
Practice Address - Fax:570-489-5060
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD235Z00000X
PASL013829235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034472200001Medicaid