1548591621 NPI number — MRS. MAUREEN RENEE VREDENBURGH M.A., CCC-SLP

Table of content: MRS. MAUREEN RENEE VREDENBURGH M.A., CCC-SLP (NPI 1548591621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548591621 NPI number — MRS. MAUREEN RENEE VREDENBURGH M.A., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VREDENBURGH
Provider First Name:
MAUREEN
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCABE
Provider Other First Name:
MAUREEN
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A., CCC-SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548591621
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4902 EDGEWORTH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANLIUS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13104-2109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-359-6900
Provider Business Mailing Address Fax Number:
315-359-6900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5820 HERITAGE LANDING DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13057-9378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-326-3351
Provider Business Practice Location Address Fax Number:
315-701-1131
Provider Enumeration Date:
01/29/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  012107-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)