Provider Demographics
NPI:1821083130
Name:SHINNICK, MARY ANN (LISW)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:SHINNICK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 CARLISLE BLVD NE
Mailing Address - Street 2:SUITE J
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4565
Mailing Address - Country:US
Mailing Address - Phone:505-459-7565
Mailing Address - Fax:505-294-5887
Practice Address - Street 1:4004 CARLISLE BLVD NE
Practice Address - Street 2:SUITE J
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4565
Practice Address - Country:US
Practice Address - Phone:505-459-7565
Practice Address - Fax:505-294-5887
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI04569104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM100096Medicaid
NM339604401Medicare PIN