Provider Demographics
NPI:1942787643
Name:PALLEJA, MARY M (MA, SLP, TSHH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:PALLEJA
Suffix:
Gender:F
Credentials:MA, SLP, TSHH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2168 LARCH ST
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-4144
Mailing Address - Country:US
Mailing Address - Phone:516-661-1825
Mailing Address - Fax:
Practice Address - Street 1:2168 LARCH ST
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-4144
Practice Address - Country:US
Practice Address - Phone:516-661-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2031-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1932347911Medicaid