Provider Demographics
NPI:1609381672
Name:LIETHEN, MARY K (MS, CCC-SLP/L)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:K
Last Name:LIETHEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 PIN OAK CIR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-1672
Mailing Address - Country:US
Mailing Address - Phone:815-459-3023
Mailing Address - Fax:815-356-0519
Practice Address - Street 1:3223 IL ROUTE 176
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-2145
Practice Address - Country:US
Practice Address - Phone:815-459-3023
Practice Address - Fax:815-356-0519
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12027407235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist