Provider Demographics
NPI:1033459409
Name:HENDERSON-HANSEN, SHELLY LYNN
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:LYNN
Last Name:HENDERSON-HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:LYNN
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:3756 GRAND AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610
Mailing Address - Country:US
Mailing Address - Phone:510-444-8732
Mailing Address - Fax:
Practice Address - Street 1:3756 GRAND AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610
Practice Address - Country:US
Practice Address - Phone:510-444-8732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16661235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist