Provider Demographics
NPI:1235839093
Name:MACK, SHANIQUA LA'SHAE
Entity Type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:LA'SHAE
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANIQUA
Other - Middle Name:LA'SHAE
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:211 COUNTY ROAD 2781
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-6194
Mailing Address - Country:US
Mailing Address - Phone:903-754-0059
Mailing Address - Fax:
Practice Address - Street 1:211 COUNTY ROAD 2781
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TX
Practice Address - Zip Code:75633-6194
Practice Address - Country:US
Practice Address - Phone:903-754-0059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX430262355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant