Provider Demographics
NPI:1356594733
Name:VAN DEMARK, MARY (SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VAN DEMARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 737
Mailing Address - Street 2:
Mailing Address - City:LAKE KATRINE
Mailing Address - State:NY
Mailing Address - Zip Code:12449-0737
Mailing Address - Country:US
Mailing Address - Phone:845-247-0668
Mailing Address - Fax:845-246-3710
Practice Address - Street 1:21 SPADA DR
Practice Address - Street 2:
Practice Address - City:SAUGERTIES
Practice Address - State:NY
Practice Address - Zip Code:12477-4481
Practice Address - Country:US
Practice Address - Phone:845-247-0668
Practice Address - Fax:845-246-3710
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004379235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist