Provider Demographics
NPI:1194104620
Name:PUENTES, MALLORY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:PUENTES
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 1:2516 14TH AVE W APT 301
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-2108
Mailing Address - Country:US
Mailing Address - Phone:714-604-6576
Mailing Address - Fax:
Practice Address - Street 1:1031 SW 130TH ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98146-3132
Practice Address - Country:US
Practice Address - Phone:206-242-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 60482892235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist