Provider Demographics
NPI:1023401825
Name:SHAW, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:SHAW
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 1:613 N HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-8120
Mailing Address - Country:US
Mailing Address - Phone:208-353-7776
Mailing Address - Fax:
Practice Address - Street 1:3115 N SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-4129
Practice Address - Country:US
Practice Address - Phone:208-401-6401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-2657235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist