Provider Demographics
NPI:1245549385
Name:GLEASON, MARYGRACE (MA,CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:MARYGRACE
Middle Name:
Last Name:GLEASON
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 1:175 SEQUAMS LANE CTR
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4529
Mailing Address - Country:US
Mailing Address - Phone:631-661-2307
Mailing Address - Fax:
Practice Address - Street 1:175 SEQUAMS LANE CENTER
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4529
Practice Address - Country:US
Practice Address - Phone:631-661-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist