MEDICARE: MARY JO THERESA LOUGHLIN MS, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	018103-1	NY

General Provider Information

NPI Number	:	1972762441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JO THERESA LOUGHLIN MS, CCC-SLP

Provider Business Mailing Address
First Line	:	2805 EVE ANN DR
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-4288
Country	:	US
Telephone Number	:	631-678-2216
Fax Number	:	631-678-2216

Provider Business Practice Location Address
First Line	:	125 E BETHPAGE RD
Second Line	:	SUITE 5
City	:	PLAINVIEW
State	:	NY
Zip	:	11803-4228
Country	:	US
Telephone Number	:	516-731-5588
Fax Number	:	516-567-9049

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	01/02/2014

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