Healthcare Provider Details

I. General information

NPI: 1598676314
Provider Name (Legal Business Name): HEADWATERS PEDIATRIC THERAPIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8405 LA VENTURA CT NW
ALBUQUERQUE NM
87120-5352
US

IV. Provider business mailing address

8405 LA VENTURA CT NW
ALBUQUERQUE NM
87120-5352
US

V. Phone/Fax

Practice location:
  • Phone: 505-610-4076
  • Fax:
Mailing address:
  • Phone: 505-610-4076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: SHANNON CARRYN TROUTMAN
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: CCC-SLP
Phone: 505-610-4076