Provider Demographics
NPI:1932394327
Name:GREEN, MARY JANE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JANE
Last Name:GREEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5722 E. CALLE CAMELIA
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018
Mailing Address - Country:US
Mailing Address - Phone:480-947-1260
Mailing Address - Fax:
Practice Address - Street 1:8700 SOUTH KYRENE ROAD
Practice Address - Street 2:MAIL STOP #9
Practice Address - City:TEMPE, ARIZONA
Practice Address - State:AZ
Practice Address - Zip Code:85284
Practice Address - Country:US
Practice Address - Phone:480-783-4024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0053235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist