Provider Demographics
NPI:1609977701
Name:TOOTHAKER, MARYELLEN B (MA,CCC-A)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:B
Last Name:TOOTHAKER
Suffix:
Gender:F
Credentials:MA,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BEECHLAND RD
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-2539
Mailing Address - Country:US
Mailing Address - Phone:207-664-2123
Mailing Address - Fax:207-667-0706
Practice Address - Street 1:77 BEECHLAND RD
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-2539
Practice Address - Country:US
Practice Address - Phone:207-664-2123
Practice Address - Fax:207-667-0706
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP1053231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VX0283Medicare PIN
04346401Medicare PIN
ME04346402Medicare PIN