Provider Demographics
NPI:1124274071
Name:CALDERONE, MARY LYNN (MACCCA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LYNN
Last Name:CALDERONE
Suffix:
Gender:F
Credentials:MACCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 N SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-3739
Mailing Address - Country:US
Mailing Address - Phone:309-343-9393
Mailing Address - Fax:
Practice Address - Street 1:360 E LOSEY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2843
Practice Address - Country:US
Practice Address - Phone:309-343-4448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147.000705231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR03360Medicare PIN