Provider Demographics
NPI:1346768751
Name:EBLIN, SHAE NICOLE
Entity Type:Individual
Prefix:
First Name:SHAE
Middle Name:NICOLE
Last Name:EBLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4031 SELMAVILLE RD APT A
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-5869
Mailing Address - Country:US
Mailing Address - Phone:618-315-9601
Mailing Address - Fax:
Practice Address - Street 1:3185 SELMAVILLE RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-6603
Practice Address - Country:US
Practice Address - Phone:618-548-2416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242004329235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist