Provider Demographics
NPI:1629398995
Name:PYFROM, MARY PELLERIN (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PELLERIN
Last Name:PYFROM
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:GRACE
Other - Last Name:PELLERIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:PCD1017
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-6750
Practice Address - Country:US
Practice Address - Phone:813-974-9844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6276235Z00000X
FLSA13673235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015807300Medicaid
FLS01CEOtherBLUE CROSS BLUE SHIELD
FL015807300Medicaid