Healthcare Provider Details

I. General information

NPI: 1386086114
Provider Name (Legal Business Name): MARY ANNE ENSOR M.A., CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13321 SUNFISH DR
HUDSON FL
34667-1627
US

IV. Provider business mailing address

13321 SUNFISH DR
HUDSON FL
34667-1627
US

V. Phone/Fax

Practice location:
  • Phone: 727-378-8853
  • Fax:
Mailing address:
  • Phone: 727-378-8853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 10475
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: