Provider Demographics
NPI:1275844490
Name:HOUSTON, MARY W (SLP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:W
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N WESTBERRY ST
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-1741
Mailing Address - Country:US
Mailing Address - Phone:229-347-4729
Mailing Address - Fax:
Practice Address - Street 1:807 S ISABELLA ST
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-7554
Practice Address - Country:US
Practice Address - Phone:229-776-6961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003776235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist