Provider Demographics
NPI:1427561158
Name:SHELTON, MALLORY VAIL DIPPOLD (MS, CCC- SLP)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:VAIL DIPPOLD
Last Name:SHELTON
Suffix:
Gender:F
Credentials:MS, CCC- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10350 UNION GROVE RD
Mailing Address - Street 2:
Mailing Address - City:GLADEWATER
Mailing Address - State:TX
Mailing Address - Zip Code:75647-3646
Mailing Address - Country:US
Mailing Address - Phone:903-736-9413
Mailing Address - Fax:
Practice Address - Street 1:10350 UNION GROVE RD
Practice Address - Street 2:
Practice Address - City:GLADEWATER
Practice Address - State:TX
Practice Address - Zip Code:75647-3646
Practice Address - Country:US
Practice Address - Phone:903-736-9413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106435235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist