Provider Demographics
NPI:1013454198
Name:WHEATLEY, MARY (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WHEATLEY
Suffix:
Gender:F
Credentials:MED, 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:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-1288
Mailing Address - Country:US
Mailing Address - Phone:910-640-0856
Mailing Address - Fax:910-640-0857
Practice Address - Street 1:123 E COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-4103
Practice Address - Country:US
Practice Address - Phone:910-640-0856
Practice Address - Fax:910-640-0857
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6406235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist