Provider Demographics
NPI:1144729161
Name:SHAFER, MARY GRACE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:SHAFER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 SPRINGDALE DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3816
Mailing Address - Country:US
Mailing Address - Phone:615-516-4488
Mailing Address - Fax:
Practice Address - Street 1:3301 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2908
Practice Address - Country:US
Practice Address - Phone:682-509-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114284235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist