Provider Demographics
NPI:1497950216
Name:HENNESSY, MAUREEN ELLA (MACCCSLP)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:ELLA
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1998 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:POMEROY
Mailing Address - State:OH
Mailing Address - Zip Code:45769-1298
Mailing Address - Country:US
Mailing Address - Phone:740-992-1415
Mailing Address - Fax:
Practice Address - Street 1:36759 ROCKSPRINGS RD
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:OH
Practice Address - Zip Code:45769-9730
Practice Address - Country:US
Practice Address - Phone:740-992-6606
Practice Address - Fax:740-992-2678
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP4922235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0410817Medicaid