Provider Demographics
NPI:1205513421
Name:HALL, MARY AUDRAH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:AUDRAH
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470477 E 1125 RD
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-7438
Mailing Address - Country:US
Mailing Address - Phone:918-315-7599
Mailing Address - Fax:
Practice Address - Street 1:1117 S DOUGLAS BLVD STE F
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5265
Practice Address - Country:US
Practice Address - Phone:405-259-9478
Practice Address - Fax:405-259-8332
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6385235Z00000X
AR202660235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist