Provider Demographics
NPI:1588979637
Name:SEPPILU, MARY ANN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:SEPPILU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:
Other - Last Name:SEPPILU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:306 WEST 5TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762-0966
Mailing Address - Country:US
Mailing Address - Phone:907-443-3311
Mailing Address - Fax:907-443-5915
Practice Address - Street 1:306 WEST 5TH AVENUE
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762-0966
Practice Address - Country:US
Practice Address - Phone:907-443-3311
Practice Address - Fax:907-443-5915
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AK09-1028-IV172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health