Provider Demographics
NPI:1417263526
Name:COBURN, MARY KATHRYN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHRYN
Last Name:COBURN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2413 PACIFIC AVE SE STE A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2087
Mailing Address - Country:US
Mailing Address - Phone:360-350-2220
Mailing Address - Fax:855-814-8815
Practice Address - Street 1:2413 PACIFIC AVE SE STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2087
Practice Address - Country:US
Practice Address - Phone:360-350-2220
Practice Address - Fax:855-814-8815
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
WALL 60390353235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist