Provider Demographics
NPI:1629383260
Name:BRADBERRY, SHALAKO (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHALAKO
Middle Name:
Last Name:BRADBERRY
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 HILLRISE CIR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4759
Mailing Address - Country:US
Mailing Address - Phone:575-522-9500
Mailing Address - Fax:575-523-1108
Practice Address - Street 1:1350 HILLRISE CIR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4759
Practice Address - Country:US
Practice Address - Phone:575-522-9500
Practice Address - Fax:575-523-1108
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist