Provider Demographics
NPI:1841503976
Name:DETTMAN, MARY JANE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:JANE
Last Name:DETTMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 CONFEDERATE CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7473
Mailing Address - Country:US
Mailing Address - Phone:843-769-4836
Mailing Address - Fax:
Practice Address - Street 1:283 CONFEDERATE CIR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7473
Practice Address - Country:US
Practice Address - Phone:843-769-4836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-18
Last Update Date:2010-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3146235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist