Basic Information
| Provider Information | |||||||||
| NPI: | 1548591621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VREDENBURGH | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCABE | ||||||||
| OtherFirstName: | MAUREEN | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A., CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4902 EDGEWORTH DR | ||||||||
| Address2: | |||||||||
| City: | MANLIUS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131042109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153596900 | ||||||||
| FaxNumber: | 3153596900 | ||||||||
| Practice Location | |||||||||
| Address1: | 5820 HERITAGE LANDING DR | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130579378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153263351 | ||||||||
| FaxNumber: | 3157011131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2010 | ||||||||
| LastUpdateDate: | 01/29/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 012107-1 | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.