Healthcare Provider Details

I. General information

NPI: 1063928125
Provider Name (Legal Business Name): SHELLY GRACE LOZANO MARIANO CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 02/26/2023
Certification Date: 02/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12036 64TH AVE S
SEATTLE WA
98178-3603
US

IV. Provider business mailing address

12036 64TH AVE S
SEATTLE WA
98178-3603
US

V. Phone/Fax

Practice location:
  • Phone: 206-785-5898
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number61206262
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: