Provider Demographics
NPI:1033312319
Name:FAULKNER, MARY KATHLEEN
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:KATHLEEN
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-1511
Mailing Address - Country:US
Mailing Address - Phone:765-490-2049
Mailing Address - Fax:765-423-4146
Practice Address - Street 1:2204 N 22ND ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-1511
Practice Address - Country:US
Practice Address - Phone:765-490-2049
Practice Address - Fax:765-423-4146
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist