Healthcare Provider Details

I. General information

NPI: 1396917027
Provider Name (Legal Business Name): MARY ELAINE RAINWATER M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23047 E 830 RD
WELLING OK
74471-2144
US

IV. Provider business mailing address

PO BOX 741
CHECOTAH OK
74426-0741
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-9896
  • Fax:
Mailing address:
  • Phone: 918-521-6614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3334
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: