Provider Demographics
NPI:1417152943
Name:DEINNOCENTES, MARY A (MS,CCC-SLP-A)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:DEINNOCENTES
Suffix:
Gender:F
Credentials:MS,CCC-SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 N. 200 E.
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947
Mailing Address - Country:US
Mailing Address - Phone:574-753-9855
Mailing Address - Fax:574-753-9855
Practice Address - Street 1:1325 N. 200 E.
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947
Practice Address - Country:US
Practice Address - Phone:574-753-9855
Practice Address - Fax:574-753-9855
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23001831A231H00000X
IN22001831A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist