Provider Demographics
NPI:1548537053
Name:WHITE, MARY L (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:WHITE
Suffix:
Gender:F
Credentials:MED, 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:PO BOX 1225
Mailing Address - Street 2:
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-1225
Mailing Address - Country:US
Mailing Address - Phone:970-728-3439
Mailing Address - Fax:
Practice Address - Street 1:651 WEST PACIFIC AVE.
Practice Address - Street 2:#309
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435-1225
Practice Address - Country:US
Practice Address - Phone:970-728-3439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist