Provider Demographics
NPI:1093345175
Name:BRANDON, MARY ANN (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:BRANDON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:HAYNOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:802 E US HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-7424
Mailing Address - Country:US
Mailing Address - Phone:219-861-3131
Mailing Address - Fax:
Practice Address - Street 1:802 E US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7424
Practice Address - Country:US
Practice Address - Phone:219-861-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006257A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist