Provider Demographics
NPI:1740420017
Name:WHITTENBURG, MARY ROSE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ROSE
Last Name:WHITTENBURG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ROSE
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:10450 BRIAN MOONEY AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-2809
Mailing Address - Country:US
Mailing Address - Phone:915-598-6616
Mailing Address - Fax:
Practice Address - Street 1:10450 BRIAN MOONEY AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-2809
Practice Address - Country:US
Practice Address - Phone:915-598-6616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009317235Z00000X
TX108696235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist