Provider Demographics
NPI:1639512247
Name:UNDERWOOD, MARK A (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SNOW AVE
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3851
Mailing Address - Country:US
Mailing Address - Phone:509-967-6332
Mailing Address - Fax:
Practice Address - Street 1:615 SNOW AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3851
Practice Address - Country:US
Practice Address - Phone:509-967-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60314859235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist