Provider Demographics
NPI:1376828152
Name:DAHL, SHELLEY CHRISTINE (SLP)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:CHRISTINE
Last Name:DAHL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:CHRISTINE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3311 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3704
Mailing Address - Country:US
Mailing Address - Phone:904-396-1462
Mailing Address - Fax:904-396-1199
Practice Address - Street 1:3311 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3704
Practice Address - Country:US
Practice Address - Phone:904-396-1462
Practice Address - Fax:904-396-1199
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8778235Z00000X
FLSA12343235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist