Provider Demographics
NPI:1801012679
Name:PRICE, MARY B (MS CCC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:PRICE
Suffix:
Gender:F
Credentials:MS CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E13240 E HILLSDALE DR
Mailing Address - Street 2:
Mailing Address - City:FALL CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54742-4209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:E13240 E HILLSDALE DR
Practice Address - Street 2:
Practice Address - City:FALL CREEK
Practice Address - State:WI
Practice Address - Zip Code:54742-4209
Practice Address - Country:US
Practice Address - Phone:715-672-3909
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
WI1151-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42706800Medicaid
WI391826964012OtherANTHEM BLUE CROSS