Provider Demographics
NPI:1568669463
Name:BERENBERG, MARYAM S (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARYAM
Middle Name:S
Last Name:BERENBERG
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 1:1100 MILL RUN DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-1914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2535 LONE STAR DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:877-626-7003
Practice Address - Fax:214-741-3655
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31294235Z00000X
TX104192235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist