Provider Demographics
NPI:1013141894
Name:IANDOLO, MARY (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:IANDOLO
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9661 CAMBERLEY CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-5744
Mailing Address - Country:US
Mailing Address - Phone:407-468-8205
Mailing Address - Fax:
Practice Address - Street 1:12702 SCIENCE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-3016
Practice Address - Country:US
Practice Address - Phone:407-281-0441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9308235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001108100Medicaid