Provider Demographics
NPI:1528763562
Name:ROYSTER, MARY KATHRYN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:ROYSTER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:ROYSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17100 E SHEA BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-6663
Mailing Address - Country:US
Mailing Address - Phone:509-850-2009
Mailing Address - Fax:
Practice Address - Street 1:17100 E SHEA BLVD STE 600
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-6663
Practice Address - Country:US
Practice Address - Phone:509-850-2009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-31
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP14556235Z00000X
235Z00000X
WALL61276959235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLP14556Medicaid
WA2240896Medicaid