Provider Demographics
NPI:1750411252
Name:MACIAS, SHELLY A (LAT)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:A
Last Name:MACIAS
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 COUNTY ROAD 7450
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-6937
Mailing Address - Country:US
Mailing Address - Phone:806-687-1057
Mailing Address - Fax:
Practice Address - Street 1:3307 VICKSBURG AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-2321
Practice Address - Country:US
Practice Address - Phone:806-766-0632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT 14242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer