Provider Demographics
NPI:1467646299
Name:WALTZ, MARY R (MA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:R
Last Name:WALTZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3685 S BASCOM AVE
Mailing Address - Street 2:#43
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-7076
Mailing Address - Country:US
Mailing Address - Phone:408-696-9690
Mailing Address - Fax:
Practice Address - Street 1:3685 S BASCOM AVE
Practice Address - Street 2:#43
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-7076
Practice Address - Country:US
Practice Address - Phone:408-696-9690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP15170235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist