Provider Demographics
NPI:1346551942
Name:BOLHAFNER, SHELBY L (SLP)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:L
Last Name:BOLHAFNER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:L
Other - Last Name:WALCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 VIRGIL ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2637
Mailing Address - Country:US
Mailing Address - Phone:636-272-1059
Mailing Address - Fax:636-980-1946
Practice Address - Street 1:110 VIRGIL ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2637
Practice Address - Country:US
Practice Address - Phone:636-272-1059
Practice Address - Fax:636-980-1946
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010019816235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist