Provider Demographics
NPI:1033638143
Name:QUALTER, MARY JO (MA,CCC,SLP/L)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:QUALTER
Suffix:
Gender:F
Credentials:MA,CCC,SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 S SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3726
Mailing Address - Country:US
Mailing Address - Phone:708-284-1143
Mailing Address - Fax:
Practice Address - Street 1:10100 S SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3726
Practice Address - Country:US
Practice Address - Phone:708-284-1143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist