Provider Demographics
NPI:1952637654
Name:DEDRICK, MARILYN
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:DEDRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 ROUTE 9G
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538-2169
Mailing Address - Country:US
Mailing Address - Phone:845-229-8370
Mailing Address - Fax:
Practice Address - Street 1:230 NORTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1328
Practice Address - Country:US
Practice Address - Phone:845-452-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010716-0235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist