Provider Demographics
NPI:1366983066
Name:MEREDITH, THERESA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MEREDITH
Suffix:
Gender:F
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 1:3285 GILLESPIE RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-5621
Mailing Address - Country:US
Mailing Address - Phone:607-427-4529
Mailing Address - Fax:
Practice Address - Street 1:435 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1606
Practice Address - Country:US
Practice Address - Phone:607-763-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004444-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist