Basic Information
| Provider Information | |||||||||
| NPI: | 1821356106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LADEWIG | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | B | ||||||||
| OtherFirstName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1880 BRYANT AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104605110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186656414 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 979 CROSS BRONX EXPY | ||||||||
| Address2: | SR NORTH | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104604885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186657565 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2012 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 021087-1 | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 03593280 | 05 | NY | MEDICAID |