Provider Demographics
NPI:1164524203
Name:CARNEY, MARY SUSAN (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:CARNEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:CARNEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SLP
Mailing Address - Street 1:817 WASHINGTON BLVD APT A
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4920
Mailing Address - Country:US
Mailing Address - Phone:708-848-0882
Mailing Address - Fax:
Practice Address - Street 1:3105 N WILKE RD
Practice Address - Street 2:SUITE H
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-1495
Practice Address - Country:US
Practice Address - Phone:847-255-8690
Practice Address - Fax:847-255-2260
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist