Healthcare Provider Details

I. General information

NPI: 1811321425
Provider Name (Legal Business Name): MARY LOUISE CRAIG M.ED, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2013
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8495 NORMANDY BLVD
JACKSONVILLE FL
32221-6701
US

IV. Provider business mailing address

10221 HUNTINGTON FOREST BLVD E
JACKSONVILLE FL
32257-7688
US

V. Phone/Fax

Practice location:
  • Phone: 904-783-3749
  • Fax:
Mailing address:
  • Phone: 770-374-2234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA13863
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202007333
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: