=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497151948
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ANNE PFROGNER MA CCC-SP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2014
-----------------------------------------------------
Last Update Date | 11/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 712 CLEVELAND RD E
-----------------------------------------------------
City | HURON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44839-1871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-988-4399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 BLOSSOM DR
-----------------------------------------------------
City | AMHERST
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44001-1169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-988-4399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP-0637
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------