Provider Demographics
NPI:1962785188
Name:NOLAN, MARY (CCC SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NOLAN
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 1:18 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:LOUDONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12211-2035
Mailing Address - Country:US
Mailing Address - Phone:518-465-9460
Mailing Address - Fax:
Practice Address - Street 1:676 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-2216
Practice Address - Country:US
Practice Address - Phone:518-858-2126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0111851235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist