Provider Demographics
NPI:1033240585
Name:GAGNEPAIN, MARY SHARYLE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SHARYLE
Last Name:GAGNEPAIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MRS
Other - First Name:MICKIE
Other - Middle Name:
Other - Last Name:GAGNEPAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:3109 N 46TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-6535
Mailing Address - Country:US
Mailing Address - Phone:602-347-2235
Mailing Address - Fax:602-347-2220
Practice Address - Street 1:8430 N 39TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-4778
Practice Address - Country:US
Practice Address - Phone:602-347-2235
Practice Address - Fax:602-347-2220
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ#SLPL0183235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ558992Medicaid