Provider Demographics
NPI:1851430953
Name:MCGILLICUDDY, MARJORIE Q (MED)
Entity Type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:Q
Last Name:MCGILLICUDDY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 N MEADOWS RD
Mailing Address - Street 2:SLP ASSOCIATES, PC
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-2317
Mailing Address - Country:US
Mailing Address - Phone:508-359-4532
Mailing Address - Fax:508-359-0198
Practice Address - Street 1:5 N MEADOWS RD
Practice Address - Street 2:SLP ASSOCIATES, PC
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-2317
Practice Address - Country:US
Practice Address - Phone:508-359-4532
Practice Address - Fax:508-359-0198
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA881235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASG0013OtherBCBS SPEECH GROUP
MA626557OtherHPHC SPEECH GROUP
MA620733OtherTUFTS GROUP
MA3668706OtherAETNA GROUP
MA226538Medicare ID - Type UnspecifiedMEDICARE A-ORF