Provider Demographics
NPI:1124524830
Name:HECKERT, MALLORY RUTH (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:RUTH
Last Name:HECKERT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MISS
Other - First Name:MALLORY
Other - Middle Name:RUTH
Other - Last Name:GOULD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:6249 MUIRFIELD DR SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-7401
Mailing Address - Country:US
Mailing Address - Phone:319-535-2077
Mailing Address - Fax:
Practice Address - Street 1:6249 MUIRFIELD DR SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-7401
Practice Address - Country:US
Practice Address - Phone:319-535-2077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081282235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist