Basic Information
| Provider Information | |||||||||
| NPI: | 1326592098 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKEAN | ||||||||
| FirstName: | MARIELLE | ||||||||
| MiddleName: | VIRGINIA | ||||||||
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| Credential: | M.A., SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 NE NEFF RD | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 NE NEFF RD | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417066843 | ||||||||
| FaxNumber: | 5413983444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2016 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | PSLP.0000159 | CO | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 016215 | OR | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.