Healthcare Provider Details

I. General information

NPI: 1366653008
Provider Name (Legal Business Name): MARY SHAIN SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 SHAKER RD
NEW LONDON NH
03257-5954
US

IV. Provider business mailing address

28 SHAKER RD
NEW LONDON NH
03257-5954
US

V. Phone/Fax

Practice location:
  • Phone: 603-526-2940
  • Fax: 603-526-2940
Mailing address:
  • Phone: 603-526-2940
  • Fax: 603-526-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number30761482
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0288
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: