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General NPI Number Information
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NPI Number | 1376058669
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Entity Type | Individual
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Provider Name | MATTIE MALLOY MARKS M.ED. CF-SLP
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Gender | Female
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Dates
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Enumeration Date | 12/07/2017
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Last Update Date | 12/07/2017
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Provider Practice Location Address
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Address Line | 10605 CARTER ST SE
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City | YELM
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State | WA
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Zip | 98597-8486
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Country | US
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Telephone | 360-458-6020
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Fax |
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Provider Business Mailing Address
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Address Line | 1695 SEQUALITCHEW DR UNIT 102
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City | DUPONT
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State | WA
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Zip | 98327-6837
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Country | US
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Telephone | 678-790-0933
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 60772408
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License Number State | WA
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