Provider Demographics
NPI:1306898580
Name:EDELSON-SISKIN, MARA JAYNE (MSCCC-SLP)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:JAYNE
Last Name:EDELSON-SISKIN
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 E 64TH ST
Mailing Address - Street 2:APT. 11C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-6730
Mailing Address - Country:US
Mailing Address - Phone:646-338-9852
Mailing Address - Fax:
Practice Address - Street 1:340 E 24TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4019
Practice Address - Country:US
Practice Address - Phone:212-585-6236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014886-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist