Provider Demographics
NPI:1760622542
Name:KILLEEN-MCDERMOTT, MARY ELIZABETH (MA, CCC, SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:KILLEEN-MCDERMOTT
Suffix:
Gender:F
Credentials:MA, CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 POTTER BLVD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTWATERS
Mailing Address - State:NY
Mailing Address - Zip Code:11718-1616
Mailing Address - Country:US
Mailing Address - Phone:631-647-7799
Mailing Address - Fax:
Practice Address - Street 1:252 ISLIP AVE
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3029
Practice Address - Country:US
Practice Address - Phone:631-581-6800
Practice Address - Fax:631-581-6814
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011059-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist