Provider Demographics
NPI:1629382361
Name:SHIVELY, PATRICIA DIANE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:DIANE
Last Name:SHIVELY
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 1:150 BUCK RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:DRUMS
Mailing Address - State:PA
Mailing Address - Zip Code:18222
Mailing Address - Country:US
Mailing Address - Phone:570-788-6644
Mailing Address - Fax:
Practice Address - Street 1:150 BUCK RIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:DRUMS
Practice Address - State:PA
Practice Address - Zip Code:18222
Practice Address - Country:US
Practice Address - Phone:570-788-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL005344L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASL005344LOtherLICENSE