Provider Demographics
NPI:1578045506
Name:BRATCHER, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:BRATCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 FORTUNA DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8210
Mailing Address - Country:US
Mailing Address - Phone:505-599-8625
Mailing Address - Fax:
Practice Address - Street 1:5840 FORTUNA DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-8210
Practice Address - Country:US
Practice Address - Phone:505-599-8625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCF6493235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist