MEDICARE: MRS. MARY K LIETHEN M.S., CCC-SLP/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	12027407	IL

General Provider Information

NPI Number	:	1609381672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY K LIETHEN M.S., CCC-SLP/L

Provider Business Mailing Address
First Line	:	901 PIN OAK CIR
Second Line	:
City	:	CARY
State	:	IL
Zip	:	60013-1672
Country	:	US
Telephone Number	:	815-459-3023
Fax Number	:	815-356-0519

Provider Business Practice Location Address
First Line	:	3223 IL ROUTE 176
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-2145
Country	:	US
Telephone Number	:	815-459-3023
Fax Number	:	815-356-0519

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2017
Last Update Date	:	07/21/2022

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