Provider Demographics
NPI:1497200273
Name:WILSHER, MALLORY RENEE MARY (MS)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:RENEE MARY
Last Name:WILSHER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 BAY ARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-4667
Mailing Address - Country:US
Mailing Address - Phone:352-339-3145
Mailing Address - Fax:
Practice Address - Street 1:219 BAY ARBOR BLVD
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-4667
Practice Address - Country:US
Practice Address - Phone:352-339-3145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ7730235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist