Provider Demographics
NPI:1629272448
Name:DYCZKO, MARY JEAN J (CCC/SLP, TSHH, ATP)
Entity Type:Individual
Prefix:MS
First Name:MARY JEAN
Middle Name:J
Last Name:DYCZKO
Suffix:
Gender:F
Credentials:CCC/SLP, TSHH, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47-03 168 STREET
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358
Mailing Address - Country:US
Mailing Address - Phone:917-969-1664
Mailing Address - Fax:
Practice Address - Street 1:47-03 168 STREET
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358
Practice Address - Country:US
Practice Address - Phone:917-969-1664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008481-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY008481Medicaid