Provider Demographics
NPI:1841731528
Name:MCDANIEL, MARY (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:MCDANIEL
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 1:2180 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-9253
Mailing Address - Country:US
Mailing Address - Phone:601-249-1629
Mailing Address - Fax:601-249-1557
Practice Address - Street 1:2180 MARTIN RD
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:MS
Practice Address - Zip Code:39666-9253
Practice Address - Country:US
Practice Address - Phone:601-249-1629
Practice Address - Fax:601-249-1557
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS0972235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist