Provider Demographics
NPI:1669789590
Name:CIVIELLO, PATRICK WILLIAM (MA, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:WILLIAM
Last Name:CIVIELLO
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:MSAD 6, 100 MAIN STREET
Mailing Address - City:BAR MILLS
Mailing Address - State:ME
Mailing Address - Zip Code:04004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN STREET
Practice Address - Street 2:SAD 6
Practice Address - City:BAR MILLS
Practice Address - State:ME
Practice Address - Zip Code:04004-0038
Practice Address - Country:US
Practice Address - Phone:207-929-5955
Practice Address - Fax:207-929-3831
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP889235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist