Provider Demographics
NPI:1770745911
Name:DEYO, MARY KATHERINE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:DEYO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FOURNIER RD
Mailing Address - Street 2:CONWAY GRAMMAR SCHOOL
Mailing Address - City:CONWAY
Mailing Address - State:MA
Mailing Address - Zip Code:01341-9766
Mailing Address - Country:US
Mailing Address - Phone:413-369-4239
Mailing Address - Fax:
Practice Address - Street 1:24 FOURNIER RD
Practice Address - Street 2:CONWAY GRAMMAR SCHOOL
Practice Address - City:CONWAY
Practice Address - State:MA
Practice Address - Zip Code:01341-9766
Practice Address - Country:US
Practice Address - Phone:413-369-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7244235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7244OtherCOMMONWEALTH OF MASSACHUSETTS PROFESSIONAL LICENSE
MA414649OtherCOMMONWEALTH OF MASSACHUSETTS EDUCATOR'S LICENSE
12102931OtherASHA CERTIFICATION