Provider Demographics
NPI:1528043411
Name:MANNELLO, DEBORAH (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:
Last Name:MANNELLO
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:PO BOX 3568
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12402-3568
Mailing Address - Country:US
Mailing Address - Phone:845-331-2568
Mailing Address - Fax:
Practice Address - Street 1:211 HURLEY AVENUVE
Practice Address - Street 2:SUITE 1
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-2400
Practice Address - Country:US
Practice Address - Phone:845-331-2568
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001052235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
M12121OtherPIN BLUE CROSS BLUE SHIEL