Basic Information
| Provider Information | |||||||||
| NPI: | 1669994307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HINSHAW | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BLAKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4668 PEMBROKE BLVD STE 115 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234556423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576488562 | ||||||||
| FaxNumber: | 7576488564 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 PROVIDENCE RD STE 80 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234644128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674604 | ||||||||
| FaxNumber: | 7574674604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2017 | ||||||||
| LastUpdateDate: | 07/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2202008532 | VA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 2202008532 | 01 | VA | VIRGINIA LICENSE | OTHER |