Provider Demographics
NPI:1801015235
Name:SHADE, MOLLY LYNN (MA CF SLP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:LYNN
Last Name:SHADE
Suffix:
Gender:F
Credentials:MA CF SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7209 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2021
Mailing Address - Country:US
Mailing Address - Phone:317-288-7606
Mailing Address - Fax:
Practice Address - Street 1:729 W. 35TH ST.
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953
Practice Address - Country:US
Practice Address - Phone:765-674-3371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46001693A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist