Provider Demographics
NPI:1891845954
Name:MCCRACKEN, MARY M (ST)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 NW SCHOLD PL
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9504
Mailing Address - Country:US
Mailing Address - Phone:360-337-7422
Mailing Address - Fax:360-698-7488
Practice Address - Street 1:10516 SILVERDALE WAY NW STE 110D
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8745
Practice Address - Country:US
Practice Address - Phone:360-307-7556
Practice Address - Fax:360-698-7488
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003449235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0176424OtherL&I
WA0176424OtherL&I