Healthcare Provider Details

I. General information

NPI: 1194242354
Provider Name (Legal Business Name): MARY KATHERINE LAWLESS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4986 WADESVILLE RD
BELLEVILLE WV
26133-8362
US

IV. Provider business mailing address

4986 WADESVILLE RD
BELLEVILLE WV
26133-8362
US

V. Phone/Fax

Practice location:
  • Phone: 330-401-7800
  • Fax:
Mailing address:
  • Phone: 330-401-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP.13937
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: