Provider Demographics
NPI:1184197741
Name:PESCADOR, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PESCADOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2343
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-0343
Mailing Address - Country:US
Mailing Address - Phone:808-639-1276
Mailing Address - Fax:
Practice Address - Street 1:91-1028 KAUNOLU ST
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2823
Practice Address - Country:US
Practice Address - Phone:808-689-1280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HISP-975235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist