Provider Demographics
NPI:1841509361
Name:BLISARD, MARY F (MA, CCC/SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:BLISARD
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S BARTRAM AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-5707
Mailing Address - Country:US
Mailing Address - Phone:609-289-2625
Mailing Address - Fax:
Practice Address - Street 1:111 S BARTRAM AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-5707
Practice Address - Country:US
Practice Address - Phone:609-289-2625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJYS001611235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist