Provider Demographics
NPI:1497782577
Name:WHITAKER, MARY M (AUD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 GLACIER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2261
Mailing Address - Country:US
Mailing Address - Phone:208-282-2190
Mailing Address - Fax:
Practice Address - Street 1:650 MEMORIAL DRIVE
Practice Address - Street 2:BLDG 68
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD1193231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1580491Medicare ID - Type UnspecifiedMEDICARE ID #