Provider Demographics
NPI:1871005645
Name:WEIS, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WEIS
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 1:6213 S GALENA WAY
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80111-5433
Mailing Address - Country:US
Mailing Address - Phone:303-909-5678
Mailing Address - Fax:303-909-5678
Practice Address - Street 1:6213 S GALENA WAY
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80111-5433
Practice Address - Country:US
Practice Address - Phone:303-909-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0000143235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty