Provider Demographics
NPI:1467783456
Name:SHACKELFORD-MARTINEZ, MARY E (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:SHACKELFORD-MARTINEZ
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:EDWINNA
Other - Last Name:SHACKELFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:PO BOX 1796
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-1796
Mailing Address - Country:US
Mailing Address - Phone:575-776-3267
Mailing Address - Fax:
Practice Address - Street 1:186A RIM ROAD
Practice Address - Street 2:
Practice Address - City:ARROYO SECO
Practice Address - State:NM
Practice Address - Zip Code:87514
Practice Address - Country:US
Practice Address - Phone:575-776-3267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3322235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist