Provider Demographics
NPI:1427192996
Name:IVERSON, MARY DONNA
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DONNA
Last Name:IVERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 E NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1578
Mailing Address - Country:US
Mailing Address - Phone:815-464-5855
Mailing Address - Fax:
Practice Address - Street 1:19065 HICKORY CREEK PL STE 110
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8597
Practice Address - Country:US
Practice Address - Phone:708-478-5400
Practice Address - Fax:708-478-5300
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist