Provider Demographics
NPI:1164547873
Name:SUDHOLT, SHELBY ANN (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:ANN
Last Name:SUDHOLT
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:MISS
Other - First Name:SHELBY
Other - Middle Name:ANN
Other - Last Name:CHAMBERLAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:1610 E. SUNSHINE ST.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-742-0930
Mailing Address - Fax:417-742-2586
Practice Address - Street 1:1610 E. SUNSHINE ST.
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-742-0930
Practice Address - Fax:417-742-2586
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005025934235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO465463404Medicaid