1114264249 NPI number — MAYRE MARGARET SHUTTLEWORTH PHD, MA, LMHC, NCC

Table of content: MAYRE MARGARET SHUTTLEWORTH PHD, MA, LMHC, NCC (NPI 1114264249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114264249 NPI number — MAYRE MARGARET SHUTTLEWORTH PHD, MA, LMHC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUTTLEWORTH
Provider First Name:
MAYRE
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD, MA, LMHC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOSKISON
Provider Other First Name:
MAYRE
Provider Other Middle Name:
MARGARET
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD, MA, LMHC, NCC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114264249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
933 BRADBURY DR SE
Provider Second Line Business Mailing Address:
SUITE 2222
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87106-4374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-272-3401
Provider Business Mailing Address Fax Number:
505-272-6091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1213 UNIVERSITY BLVD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87102-1703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-272-3401
Provider Business Practice Location Address Fax Number:
505-272-6091
Provider Enumeration Date:
01/09/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  0153161 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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