Provider Demographics
NPI:1720131394
Name:MAMMEN, ASHLY (SLP)
Entity Type:Individual
Prefix:MRS
First Name:ASHLY
Middle Name:
Last Name:MAMMEN
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 1:21418 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-1808
Mailing Address - Country:US
Mailing Address - Phone:646-651-9197
Mailing Address - Fax:
Practice Address - Street 1:21418 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-1808
Practice Address - Country:US
Practice Address - Phone:646-651-9197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2012-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016266235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16551385OtherHIP PRIME HMO