Provider Demographics
NPI:1801020235
Name:MUKHERJEE, CONSTANCE S (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:S
Last Name:MUKHERJEE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 E MARIGOLD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8989
Mailing Address - Country:US
Mailing Address - Phone:812-322-4320
Mailing Address - Fax:
Practice Address - Street 1:1233 E MARIGOLD DRIVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8989
Practice Address - Country:US
Practice Address - Phone:812-322-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002199A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist