Provider Demographics
NPI:1396174504
Name:DEJONGHE, MARA WILLIS (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:WILLIS
Last Name:DEJONGHE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:WILLIS
Other - Last Name:EDELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:13 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4544
Mailing Address - Country:US
Mailing Address - Phone:857-205-0219
Mailing Address - Fax:
Practice Address - Street 1:13 LOCUST ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4544
Practice Address - Country:US
Practice Address - Phone:857-205-0219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023131235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist