Provider Demographics
NPI:1245894310
Name:TATE, MARY KATHLEEN (BS ECE; SLP-A)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLEEN
Last Name:TATE
Suffix:
Gender:F
Credentials:BS ECE; SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E NORTHERN LIGHTS BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 E. NORTHERN LIGHTS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503
Practice Address - Country:US
Practice Address - Phone:907-277-1467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
AK1456922355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician