Provider Demographics
NPI:1033272018
Name:WALLY, MARY M (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:WALLY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 WATER ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5333
Mailing Address - Country:US
Mailing Address - Phone:830-792-3300
Mailing Address - Fax:830-792-5771
Practice Address - Street 1:1901 DUTTON DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7573
Practice Address - Country:US
Practice Address - Phone:512-847-1547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100854235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist