Provider Demographics
NPI:1801024187
Name:DETWEILER, MARK (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DETWEILER
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3705
Mailing Address - Country:US
Mailing Address - Phone:541-284-4880
Mailing Address - Fax:541-485-6159
Practice Address - Street 1:1500 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3705
Practice Address - Country:US
Practice Address - Phone:541-284-4880
Practice Address - Fax:541-485-6159
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13103235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist