Healthcare Provider Details

I. General information

NPI: 1376539676
Provider Name (Legal Business Name): MARY E NOLAND MBA, MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5205 W WINSTON DR
LAVEEN AZ
85339-2819
US

IV. Provider business mailing address

PO BOX 760
LAVEEN AZ
85339-0760
US

V. Phone/Fax

Practice location:
  • Phone: 602-578-0515
  • Fax: 602-237-7791
Mailing address:
  • Phone: 602-578-0515
  • Fax: 602-237-7791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP 2151
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: