Provider Demographics
NPI:1447397229
Name:DEVINE, MARY ANNE J (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY ANNE
Middle Name:J
Last Name:DEVINE
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 1:14 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5015
Mailing Address - Country:US
Mailing Address - Phone:963-104-9302
Mailing Address - Fax:
Practice Address - Street 1:90 AIR PARK DR
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7360
Practice Address - Country:US
Practice Address - Phone:631-580-5015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007638235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist