Provider Demographics
NPI:1053322735
Name:CRITCHLEY, MARY VIRGINIA (MA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:VIRGINIA
Last Name:CRITCHLEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8932 CLIPPER DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-3313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 S EUCLID ST
Practice Address - Street 2:SUITE 6
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-1530
Practice Address - Country:US
Practice Address - Phone:714-776-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1754231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU001754Medicaid