Basic Information
Provider Information | |||||||||
NPI: | 1972838886 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | UYTTEWAAL | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS CCC/SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JOHNSTON | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS CCC/SLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2222 SULLIVAN TRL | ||||||||
Address2: |   | ||||||||
City: | EASTON | ||||||||
State: | PA | ||||||||
PostalCode: | 180407958 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009449782 | ||||||||
FaxNumber: | 6104382046 | ||||||||
Practice Location | |||||||||
Address1: | 1675 DUNLAWTON AVE | ||||||||
Address2: |   | ||||||||
City: | PORT ORANGE | ||||||||
State: | FL | ||||||||
PostalCode: | 321274755 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3867611055 | ||||||||
FaxNumber: | 3863044119 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2009 | ||||||||
LastUpdateDate: | 10/09/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA9061 | FL | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.