Provider Demographics
NPI:1093788234
Name:THORPE, MARY LYNN (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LYNN
Last Name:THORPE
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:REVNEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17280 W NORTH AVE
Mailing Address - Street 2:# 104
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4366
Mailing Address - Country:US
Mailing Address - Phone:262-780-0707
Mailing Address - Fax:262-780-0717
Practice Address - Street 1:17280 W NORTH AVE
Practice Address - Street 2:# 104
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4366
Practice Address - Country:US
Practice Address - Phone:262-780-0707
Practice Address - Fax:262-780-0717
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2205 154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist