Provider Demographics
NPI:1669512240
Name:MANNIX, DEIRDRE ANNA
Entity type:Individual
Prefix:MRS
First Name:DEIRDRE
Middle Name:ANNA
Last Name:MANNIX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-1311
Mailing Address - Country:US
Mailing Address - Phone:516-629-6349
Mailing Address - Fax:
Practice Address - Street 1:2 CALVERT DR
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-2905
Practice Address - Country:US
Practice Address - Phone:516-677-1994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09119675235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist