Provider Demographics
NPI:1609056977
Name:SHADLEY, LINDA DIANE
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:DIANE
Last Name:SHADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:DIANE
Other - Last Name:BRUTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP-T
Mailing Address - Street 1:4510 N 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-3206
Mailing Address - Country:US
Mailing Address - Phone:602-336-2931
Mailing Address - Fax:
Practice Address - Street 1:4510 N 37TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-3206
Practice Address - Country:US
Practice Address - Phone:602-336-2931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL5699235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ557986OtherALHAMBRA SCHOOL DISTRICT#