Provider Demographics
NPI:1770870503
Name:WEIDNER, MARY E (MS, CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:E
Last Name:WEIDNER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JOHN MARSHALL DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25755-0002
Mailing Address - Country:US
Mailing Address - Phone:724-272-6808
Mailing Address - Fax:
Practice Address - Street 1:1 JOHN MARSHALL DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25755-0002
Practice Address - Country:US
Practice Address - Phone:724-272-6808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL009914235Z00000X
WVSLP-1456235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist