Provider Demographics
NPI:1811321425
Name:CRAIG, MARY LOUISE (MED, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOUISE
Last Name:CRAIG
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 1:10221 HUNTINGTON FOREST BLVD E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-7688
Mailing Address - Country:US
Mailing Address - Phone:770-374-2234
Mailing Address - Fax:
Practice Address - Street 1:8495 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-6701
Practice Address - Country:US
Practice Address - Phone:904-783-3749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13863235Z00000X
VA2202007333235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist