Provider Demographics
NPI:1326353038
Name:MCJILTON, MARY T (M ED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:T
Last Name:MCJILTON
Suffix:
Gender:F
Credentials:M ED, CCC-SLP
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:
Other - Last Name:MCJILTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:M ED, CCC-SLP
Mailing Address - Street 1:2912 BALSAM ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-1516
Mailing Address - Country:US
Mailing Address - Phone:903-399-5441
Mailing Address - Fax:903-399-5441
Practice Address - Street 1:2912 BALSAM ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-1516
Practice Address - Country:US
Practice Address - Phone:903-399-5441
Practice Address - Fax:903-399-5441
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15394235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15394OtherTX LICENSE #