Provider Demographics
NPI:1306091103
Name:MARR, MINDY SUE (MS CCC, SLP)
Entity type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:SUE
Last Name:MARR
Suffix:
Gender:F
Credentials:MS 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:PO BOX 1095
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545-1095
Mailing Address - Country:US
Mailing Address - Phone:845-677-6344
Mailing Address - Fax:
Practice Address - Street 1:30 WEATHERFORD LANE
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:NY
Practice Address - Zip Code:12545
Practice Address - Country:US
Practice Address - Phone:845-677-6344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007796-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist