Provider Demographics
NPI:1669087193
Name:MALLON, COURTNEY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MALLON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BROOKSIDE DR W
Mailing Address - Street 2:
Mailing Address - City:HARRIMAN
Mailing Address - State:NY
Mailing Address - Zip Code:10926-3017
Mailing Address - Country:US
Mailing Address - Phone:845-222-4820
Mailing Address - Fax:
Practice Address - Street 1:36 BENMOSCHE RD
Practice Address - Street 2:
Practice Address - City:HARRIS
Practice Address - State:NY
Practice Address - Zip Code:12701-7014
Practice Address - Country:US
Practice Address - Phone:845-794-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029356235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist