Provider Demographics
NPI:1831491174
Name:VALANTINE, MARY LOUISE (MS)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOUISE
Last Name:VALANTINE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:HETHERINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:1719 REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3115
Mailing Address - Country:US
Mailing Address - Phone:801-647-4170
Mailing Address - Fax:801-485-0092
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT112855-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist