Provider Demographics
NPI:1609190867
Name:IVERSON, MARY COLLEEN (SLPA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:COLLEEN
Last Name:IVERSON
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 N SCOTTSDALE RD
Mailing Address - Street 2:1139
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-1500
Mailing Address - Country:US
Mailing Address - Phone:805-377-5021
Mailing Address - Fax:
Practice Address - Street 1:1535 N SCOTTSDALE RD
Practice Address - Street 2:1139
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-1500
Practice Address - Country:US
Practice Address - Phone:805-377-5021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA63192355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant