Provider Demographics
NPI:1548433022
Name:MCDIVITT, MAUREEN ANN (MEDCCC/SLP)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:ANN
Last Name:MCDIVITT
Suffix:
Gender:F
Credentials:MEDCCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 SOLITUDE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:HEDGESVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25427
Mailing Address - Country:US
Mailing Address - Phone:304-725-7793
Mailing Address - Fax:
Practice Address - Street 1:401 SOUTH QUEEN STREET
Practice Address - Street 2:BERKELEY COUNTY BOARD OF EDUCATION
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-267-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1029235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010561Medicaid