Provider Demographics
NPI:1699103283
Name:MEYER, MARK CHARLES (MA CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:CHARLES
Last Name:MEYER
Suffix:
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4273 BLACKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7908
Mailing Address - Country:US
Mailing Address - Phone:317-777-2655
Mailing Address - Fax:
Practice Address - Street 1:4273 BLACKWOOD CT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-7908
Practice Address - Country:US
Practice Address - Phone:317-777-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004482A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist