Provider Demographics
NPI:1205607520
Name:HOLBROOK, MARY K
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:HOLBROOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:DESALVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1451 E FAIRVIEW LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-0352
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3505 E MERIDIAN PARK LOOP
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7242
Practice Address - Country:US
Practice Address - Phone:907-357-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK218860235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist