Provider Demographics
NPI:1285182253
Name:DUTRA, MARY ANNE (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:DUTRA
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2848 CONCH HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7349
Mailing Address - Country:US
Mailing Address - Phone:813-731-2363
Mailing Address - Fax:813-383-4548
Practice Address - Street 1:2848 CONCH HOLLOW DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7349
Practice Address - Country:US
Practice Address - Phone:813-731-2363
Practice Address - Fax:813-383-4548
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8174235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist