Provider Demographics
NPI:1619486941
Name:EMERSON, MARY MICHELE
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MICHELE
Last Name:EMERSON
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 1:550 PRAIRIE ST
Mailing Address - Street 2:P.O. BOX 20
Mailing Address - City:KINCAID
Mailing Address - State:IL
Mailing Address - Zip Code:62540-4532
Mailing Address - Country:US
Mailing Address - Phone:217-237-4331
Mailing Address - Fax:217-237-2245
Practice Address - Street 1:510 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2106
Practice Address - Country:US
Practice Address - Phone:217-827-8675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.000747235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist