Provider Demographics
NPI:1205111457
Name:MARCELLA, MARY SHANNON (SLP-CCC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SHANNON
Last Name:MARCELLA
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-2647
Mailing Address - Country:US
Mailing Address - Phone:508-331-9999
Mailing Address - Fax:
Practice Address - Street 1:130 CONDOR ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1305
Practice Address - Country:US
Practice Address - Phone:617-569-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASP-8408-SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist