Provider Demographics
NPI:1891813317
Name:KINGSLEY, MARY KATRINA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATRINA
Last Name:KINGSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATRINA
Other - Last Name:SCHULTEIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:431 BRUSH VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BOALSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16827-1016
Mailing Address - Country:US
Mailing Address - Phone:814-574-8688
Mailing Address - Fax:
Practice Address - Street 1:3054 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-2755
Practice Address - Country:US
Practice Address - Phone:814-234-6023
Practice Address - Fax:814-234-1439
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL005526L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017296300001Medicaid