Provider Demographics
NPI:1871644427
Name:MARY WEST
Entity Type:Organization
Organization Name:MARY WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:MS , CCC-SLP
Authorized Official - Phone:904-540-8408
Mailing Address - Street 1:1432 HEATHER COURT
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092
Mailing Address - Country:US
Mailing Address - Phone:904-540-8408
Mailing Address - Fax:904-797-1627
Practice Address - Street 1:1432 HEATHER COURT
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092
Practice Address - Country:US
Practice Address - Phone:904-540-8408
Practice Address - Fax:904-797-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3573235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL883173400Medicaid