Provider Demographics
NPI:1194230284
Name:HENKE, MARY PATRICIA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:HENKE
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 1:2514 W SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-5255
Mailing Address - Country:US
Mailing Address - Phone:847-732-4588
Mailing Address - Fax:
Practice Address - Street 1:850 HIGHLAND GROVE DR
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1549
Practice Address - Country:US
Practice Address - Phone:847-955-3621
Practice Address - Fax:847-215-3268
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.002046235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist