Provider Demographics
NPI:1851698153
Name:BUCKWALD, MARY BETH (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY BETH
Middle Name:
Last Name:BUCKWALD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 POST RD STE 208
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6038
Mailing Address - Country:US
Mailing Address - Phone:203-260-8271
Mailing Address - Fax:
Practice Address - Street 1:1300 POST RD STE 208
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6038
Practice Address - Country:US
Practice Address - Phone:203-260-8271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist