Provider Demographics
NPI:1508100066
Name:SHELLENBERG, GAYLE BOCKMAN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:GAYLE
Middle Name:BOCKMAN
Last Name:SHELLENBERG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 COLONY HOUSE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-3520
Mailing Address - Country:US
Mailing Address - Phone:803-665-0000
Mailing Address - Fax:803-896-5166
Practice Address - Street 1:13 COLONY HOUSE CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-3520
Practice Address - Country:US
Practice Address - Phone:803-665-0000
Practice Address - Fax:803-896-5166
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6940101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6940OtherBOARD OF SOCIAL WORK EXAMINERS