Provider Demographics
NPI:1528199833
Name:WOOLLEN, MARY MARIATTA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARIATTA
Last Name:WOOLLEN
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 1:16 SUMMERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-8442
Mailing Address - Country:US
Mailing Address - Phone:870-904-9408
Mailing Address - Fax:
Practice Address - Street 1:16 SUMMERWOOD DR
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-8442
Practice Address - Country:US
Practice Address - Phone:870-904-9408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2058235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist