Provider Demographics
NPI:1578684445
Name:BOTCH, SHELLY L (SLP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:BOTCH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 E 3707 N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3006
Mailing Address - Country:US
Mailing Address - Phone:208-420-7740
Mailing Address - Fax:208-736-0840
Practice Address - Street 1:2520 E 3707 N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-0112
Practice Address - Country:US
Practice Address - Phone:208-420-7740
Practice Address - Fax:208-736-0840
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP1446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist