Provider Demographics
NPI:1194933085
Name:MINDRUM, JEANINE LEA (MA-CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:JEANINE
Middle Name:LEA
Last Name:MINDRUM
Suffix:
Gender:F
Credentials:MA-CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 RUGGLES ST
Mailing Address - Street 2:#2
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-2036
Mailing Address - Country:US
Mailing Address - Phone:508-366-1190
Mailing Address - Fax:508-845-2783
Practice Address - Street 1:214 LAKE ST
Practice Address - Street 2:CHILD DEVELOPMENT CENTER
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-3960
Practice Address - Country:US
Practice Address - Phone:508-856-4202
Practice Address - Fax:508-845-2783
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2743235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist