Provider Demographics
NPI:1316084734
Name:MASIONGALE, TEDD B (CCC-SLP)
Entity type:Individual
Prefix:
First Name:TEDD
Middle Name:B
Last Name:MASIONGALE
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:BROWNS SUMMIT
Mailing Address - State:NC
Mailing Address - Zip Code:27214-9704
Mailing Address - Country:US
Mailing Address - Phone:336-217-5120
Mailing Address - Fax:336-217-5127
Practice Address - Street 1:5900 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:BROWNS SUMMIT
Practice Address - State:NC
Practice Address - Zip Code:27214-9704
Practice Address - Country:US
Practice Address - Phone:336-217-5120
Practice Address - Fax:336-217-5127
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist