Provider Demographics
NPI:1427607969
Name:SHAFFER, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 S JACKSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-3334
Mailing Address - Country:US
Mailing Address - Phone:214-578-1545
Mailing Address - Fax:
Practice Address - Street 1:403 S JACKSON AVE STE 101
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-3334
Practice Address - Country:US
Practice Address - Phone:214-578-1545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-07
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019005770104100000X
TX62627104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker