Provider Demographics
NPI:1427459106
Name:RICCHIUTO, MARIAM (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:RICCHIUTO
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12040 LAKE AVE
Mailing Address - Street 2:APT. 103
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1851
Mailing Address - Country:US
Mailing Address - Phone:440-465-9370
Mailing Address - Fax:
Practice Address - Street 1:37047 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4130
Practice Address - Country:US
Practice Address - Phone:440-946-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11370235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist