Provider Demographics
NPI:1184490658
Name:MCGONIGLE, MARY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCGONIGLE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 VILLAGE WALK
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-1239
Mailing Address - Country:US
Mailing Address - Phone:484-364-8647
Mailing Address - Fax:
Practice Address - Street 1:77 W BALTIMORE PIKE STE 100B
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5639
Practice Address - Country:US
Practice Address - Phone:610-572-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL015932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist