Provider Demographics
NPI:1033686787
Name:SAN MIGUEL, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SAN MIGUEL
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 1:1207 ROCK FALLS TRCE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3775
Mailing Address - Country:US
Mailing Address - Phone:502-419-6752
Mailing Address - Fax:
Practice Address - Street 1:1207 ROCK FALLS TRCE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3775
Practice Address - Country:US
Practice Address - Phone:502-419-6752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001299A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist