Provider Demographics
NPI:1720577463
Name:ALCALA, MARY NESSA
Entity Type:Individual
Prefix:
First Name:MARY NESSA
Middle Name:
Last Name:ALCALA
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:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:NEW TOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58763-0700
Mailing Address - Country:US
Mailing Address - Phone:701-627-3718
Mailing Address - Fax:
Practice Address - Street 1:206 2ND AVE E
Practice Address - Street 2:
Practice Address - City:NEW TOWN
Practice Address - State:ND
Practice Address - Zip Code:58763-4125
Practice Address - Country:US
Practice Address - Phone:701-627-3718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
ND425091235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist