Provider Demographics
NPI:1356079545
Name:AIWANSE, MARILYN K (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:K
Last Name:AIWANSE
Suffix:
Gender:
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:K
Other - Last Name:BUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:41 OCONNOR RD
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1327
Mailing Address - Country:US
Mailing Address - Phone:585-249-7094
Mailing Address - Fax:
Practice Address - Street 1:41 OCONNOR RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1327
Practice Address - Country:US
Practice Address - Phone:585-249-7094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032318235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist