Provider Demographics
NPI:1366653008
Name:SHAIN, MARY (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHAIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 SHAKER RD
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:NH
Mailing Address - Zip Code:03257-5954
Mailing Address - Country:US
Mailing Address - Phone:603-526-2940
Mailing Address - Fax:603-526-2940
Practice Address - Street 1:28 SHAKER RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:NH
Practice Address - Zip Code:03257-5954
Practice Address - Country:US
Practice Address - Phone:603-526-2940
Practice Address - Fax:603-526-2940
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0288235Z00000X
NH30761482332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30400646Medicaid
NH30761482Medicaid