Individual
MARY RICHARDSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MA CCC-SLP
Contact information
Practice address
5930 HALLOWELL PL, FORT WAYNE, IN 46815-6214
(260) 409-0687
Mailing address
5930 HALLOWELL PL, FORT WAYNE, IN 46815-6214
(260) 409-0687
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
22004744A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12147615
ASHA
IN
01
—
22004744A
IPLA
IL
Enumeration date
04/05/2019
Last updated
04/05/2019
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