Provider Demographics
NPI:1083098578
Name:VEENENDALL, MARY JO (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:VEENENDALL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N 2ND ST STE 106
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-3708
Mailing Address - Country:US
Mailing Address - Phone:715-629-7479
Mailing Address - Fax:
Practice Address - Street 1:215 N 2ND ST STE 106
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-3708
Practice Address - Country:US
Practice Address - Phone:715-629-7479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4163-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist