Provider Demographics
NPI:1699336032
Name:WEAVER, MARY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 HIGH ST. 5TH FLOOR
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110
Mailing Address - Country:US
Mailing Address - Phone:866-600-7598
Mailing Address - Fax:
Practice Address - Street 1:184 HIGH ST. 5TH FLOOR
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110
Practice Address - Country:US
Practice Address - Phone:866-600-7598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006894235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist