Provider Demographics
NPI:1417636028
Name:PANGBORN, MARY JOSEPHINE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JOSEPHINE
Last Name:PANGBORN
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 1:3735 PARULA DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8352
Mailing Address - Country:US
Mailing Address - Phone:231-492-5823
Mailing Address - Fax:
Practice Address - Street 1:3735 PARULA DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8352
Practice Address - Country:US
Practice Address - Phone:231-492-5823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14041708235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist