Provider Demographics
NPI:1376058669
Name:MARKS, MATTIE MALLOY (MED CF-SLP)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:MALLOY
Last Name:MARKS
Suffix:
Gender:F
Credentials:MED CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 SEQUALITCHEW DR UNIT 102
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:WA
Mailing Address - Zip Code:98327-6837
Mailing Address - Country:US
Mailing Address - Phone:678-790-0933
Mailing Address - Fax:
Practice Address - Street 1:10605 CARTER ST SE
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-8486
Practice Address - Country:US
Practice Address - Phone:360-458-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60772408235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60772408OtherWASHINGTON DEPARTMENT OF HEALTH