Provider Demographics
NPI:1033630603
Name:BLANKENBAKER, MARY KATHERINE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHERINE
Last Name:BLANKENBAKER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHERINE
Other - Last Name:LITHERLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9625 E 900TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9625 E 900TH AVE
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-5005
Practice Address - Country:US
Practice Address - Phone:618-201-7141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-04
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146012074235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist