Provider Demographics
NPI:1629345046
Name:VODRA, MARY M (MSCCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:VODRA
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 BERLIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1991
Mailing Address - Country:US
Mailing Address - Phone:715-258-5521
Mailing Address - Fax:
Practice Address - Street 1:1226 BERLIN ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1991
Practice Address - Country:US
Practice Address - Phone:715-258-5521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2443-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist