Provider Demographics
NPI:1467649608
Name:GILLAN, MARY J (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:J
Last Name:GILLAN
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 1:3474 MILL RUN RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44904-9734
Mailing Address - Country:US
Mailing Address - Phone:419-884-1058
Mailing Address - Fax:
Practice Address - Street 1:335 GLESSNER AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2269
Practice Address - Country:US
Practice Address - Phone:419-526-8290
Practice Address - Fax:419-520-2878
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP8566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist