Provider Demographics
NPI:1962428615
Name:KALLSEN, MARY ANNE (MARY KALLSEN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:KALLSEN
Suffix:
Gender:F
Credentials:MARY KALLSEN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32302 HICKORY AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51108-8668
Mailing Address - Country:US
Mailing Address - Phone:712-239-4789
Mailing Address - Fax:
Practice Address - Street 1:32302 HICKORY AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51108-8668
Practice Address - Country:US
Practice Address - Phone:712-239-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1084235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist