Provider Demographics
NPI:1366758393
Name:SALAS-PROVANCE, MARLENE B (PHD)
Entity type:Individual
Prefix:DR
First Name:MARLENE
Middle Name:B
Last Name:SALAS-PROVANCE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 30001/MSC 3SPE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88003-8001
Mailing Address - Country:US
Mailing Address - Phone:575-646-2364
Mailing Address - Fax:
Practice Address - Street 1:1405 INTERNATIONAL MALL
Practice Address - Street 2:SPEECH BLDG. ROOM 158
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88003-1279
Practice Address - Country:US
Practice Address - Phone:575-646-3906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3836235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist