Basic Information
Provider Information
NPI: 1003003906
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MALONEY
FirstName: MARY
MiddleName: KAYE
NamePrefix: MRS.
NameSuffix:  
Credential: CCC-SLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 511 INDIAN HILLS APACHE TRAIL
Address2:  
City: PORTALES
State: NM
PostalCode: 881309106
CountryCode: US
TelephoneNumber: 5054782424
FaxNumber:  
Practice Location
Address1: 100 SCHOOL STREET
Address2: DORA CONSOLIDATED SCHOOLS
City: DORA
State: NM
PostalCode: 881150327
CountryCode: US
TelephoneNumber: 5054772211
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/25/2007
LastUpdateDate: 09/25/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000X1826NMY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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