Provider Demographics
NPI:1033493788
Name:WITT-GENTILE, SHELLEY A (MA/CCC-A)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:A
Last Name:WITT-GENTILE
Suffix:
Gender:F
Credentials:MA/CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 E 53RD ST
Mailing Address - Street 2:STE 103
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3058
Mailing Address - Country:US
Mailing Address - Phone:563-355-7155
Mailing Address - Fax:
Practice Address - Street 1:4009 E 53RD ST
Practice Address - Street 2:STE 103
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3058
Practice Address - Country:US
Practice Address - Phone:563-355-7155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00449231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist