Provider Demographics
NPI:1205063419
Name:MAMROUD, MARA D (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:D
Last Name:MAMROUD
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:D
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1101 ADAMS ST
Mailing Address - Street 2:APT 611
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030
Mailing Address - Country:US
Mailing Address - Phone:516-457-9121
Mailing Address - Fax:
Practice Address - Street 1:15 WEST 65TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023
Practice Address - Country:US
Practice Address - Phone:212-787-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019065235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03709579Medicaid