Basic Information
| Provider Information | |||||||||
| NPI: | 1013141894 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IANDOLO | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | MA CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9661 CAMBERLEY CIR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328365744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074688205 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12702 SCIENCE DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328263016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072810441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2009 | ||||||||
| LastUpdateDate: | 01/24/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA9308 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 001108100 | 05 | FL | MEDICAID |