Provider Demographics
NPI:1508997545
Name:UDOVICH, MARYELLEN (SLP)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:UDOVICH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:FORD
Other - Last Name:UDOVICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:318 E BASIN RD
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-4214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:318 E BASIN RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-4214
Practice Address - Country:US
Practice Address - Phone:302-323-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000367767Medicaid