Provider Demographics
NPI:1881115715
Name:VERNON, MARYAM
Entity type:Individual
Prefix:MRS
First Name:MARYAM
Middle Name:
Last Name:VERNON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARYAM
Other - Middle Name:
Other - Last Name:FORK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4727 W 147TH ST UNIT 121
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-1304
Mailing Address - Country:US
Mailing Address - Phone:310-968-6589
Mailing Address - Fax:
Practice Address - Street 1:3521 LOMITA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5040
Practice Address - Country:US
Practice Address - Phone:310-856-8528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11565235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist