Basic Information
| Provider Information | |||||||||
| NPI: | 1568583805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDERMOTT | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 CORRIZ DR SW | ||||||||
| Address2: | MARY ANN BINFORD ES | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871218311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058360623 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 CORRIZ DR SW | ||||||||
| Address2: | MARY ANN BINFORD ES | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871218311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058360623 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 1133 | NM | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 79351573 | 05 | NM | MEDICAID |