Provider Demographics
NPI:1598117954
Name:BUCKINGHAM, MALLORY A
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:BUCKINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CONNOLLY PKWY
Mailing Address - Street 2:BLDG. 17A
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-2593
Mailing Address - Country:US
Mailing Address - Phone:203-230-2815
Mailing Address - Fax:203-823-0850
Practice Address - Street 1:60 CONNOLLY PKWY
Practice Address - Street 2:BLDG. 17A
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-2593
Practice Address - Country:US
Practice Address - Phone:203-230-2815
Practice Address - Fax:203-823-0850
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002370235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist