Provider Demographics
NPI:1841493442
Name:DAHLSTROM, MARY L (CCC - SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:DAHLSTROM
Suffix:
Gender:F
Credentials:CCC - SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 AWESOME DR
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-9075
Mailing Address - Country:US
Mailing Address - Phone:360-748-8065
Mailing Address - Fax:360-748-1163
Practice Address - Street 1:126 AWESOME DR
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-9075
Practice Address - Country:US
Practice Address - Phone:360-357-3339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004482235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist