Provider Demographics
NPI:1316079866
Name:KASTLER-DAVIS, SHELLEY A (MS SLP-CCC)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:A
Last Name:KASTLER-DAVIS
Suffix:
Gender:F
Credentials:MS SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FOREST ROAD 252
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-6308
Mailing Address - Country:US
Mailing Address - Phone:505-286-0012
Mailing Address - Fax:
Practice Address - Street 1:100 FOREST ROAD 252
Practice Address - Street 2:
Practice Address - City:TIJERAS
Practice Address - State:NM
Practice Address - Zip Code:87059-6308
Practice Address - Country:US
Practice Address - Phone:505-286-0012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1569235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist