Provider Demographics
NPI:1720633845
Name:NIERODE, MARY (SA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NIERODE
Suffix:
Gender:F
Credentials:SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8477 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5028
Mailing Address - Country:US
Mailing Address - Phone:352-382-7214
Mailing Address - Fax:
Practice Address - Street 1:2021 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-8161
Practice Address - Country:US
Practice Address - Phone:527-320-0423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6896235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist