Provider Demographics
NPI:1982232526
Name:HANSON, MARY KATHERINE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:HANSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1503
Mailing Address - Country:US
Mailing Address - Phone:920-333-0100
Mailing Address - Fax:
Practice Address - Street 1:619 N FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-1714
Practice Address - Country:US
Practice Address - Phone:323-651-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25656235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist