Provider Demographics
NPI:1114402575
Name:WAISANEN, MALLORY JEAN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:JEAN
Last Name:WAISANEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9437 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:GAINES
Mailing Address - State:MI
Mailing Address - Zip Code:48436-8933
Mailing Address - Country:US
Mailing Address - Phone:810-429-8923
Mailing Address - Fax:
Practice Address - Street 1:1 HURLEY PLZ
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-429-8923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005773235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist