Provider Demographics
NPI:1639395247
Name:JUSTEN, MARY SANDRA B (MSP, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SANDRA B
Last Name:JUSTEN
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE ALVARO OBREGON
Mailing Address - Street 2:COLONIA LAZARO CARDENAS
Mailing Address - City:PUERTO ESCONDIDO
Mailing Address - State:OAXACA
Mailing Address - Zip Code:71980
Mailing Address - Country:MX
Mailing Address - Phone:01152954-582-3492
Mailing Address - Fax:
Practice Address - Street 1:12723 BARRETT DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-4101
Practice Address - Country:US
Practice Address - Phone:813-514-7425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3694235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist