Provider Demographics
NPI:1659412195
Name:MANNING, SHELLEY A
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:A
Last Name:MANNING
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:PO BOX 17
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-0017
Mailing Address - Country:US
Mailing Address - Phone:815-474-2146
Mailing Address - Fax:815-290-5133
Practice Address - Street 1:414 W HUNTER LN
Practice Address - Street 2:
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-4519
Practice Address - Country:US
Practice Address - Phone:815-474-2146
Practice Address - Fax:815-290-5133
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146-006630235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12046398OtherASHA