Provider Demographics
NPI:1346594231
Name:SCULLAWL, SHELLY (M ED CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:
Last Name:SCULLAWL
Suffix:
Gender:F
Credentials:M ED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21686 E 39TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-8787
Mailing Address - Country:US
Mailing Address - Phone:918-636-8181
Mailing Address - Fax:
Practice Address - Street 1:21686 E 39TH ST S
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-8787
Practice Address - Country:US
Practice Address - Phone:918-636-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3012235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist