Provider Demographics
NPI:1457596090
Name:DISSELKOEN, MARY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:DISSELKOEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 VAN AUKEN ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-2516
Mailing Address - Country:US
Mailing Address - Phone:616-819-2685
Mailing Address - Fax:616-819-2684
Practice Address - Street 1:1353 VAN AUKEN ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-2516
Practice Address - Country:US
Practice Address - Phone:616-819-2685
Practice Address - Fax:616-819-2684
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000230231H00000X, 231HA2400X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter