Provider Demographics
NPI:1689899411
Name:MARION, KATHERINE MCCULLOUGH (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:MCCULLOUGH
Last Name:MARION
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Mailing Address - Street 1:28 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746-1617
Mailing Address - Country:US
Mailing Address - Phone:774-233-0415
Mailing Address - Fax:
Practice Address - Street 1:915 BENNER PIKE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7395
Practice Address - Country:US
Practice Address - Phone:814-231-0138
Practice Address - Fax:814-231-1390
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7133235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011300670001Medicaid