Provider Demographics
NPI:1285168922
Name:ROSS, MARY (CCC SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 GREEN ACRES DR SW
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-5300
Mailing Address - Country:US
Mailing Address - Phone:812-972-5839
Mailing Address - Fax:
Practice Address - Street 1:1310 GREEN ACRES DR SW
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-5300
Practice Address - Country:US
Practice Address - Phone:812-972-5839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006604A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist