Provider Demographics
NPI:1730680331
Name:SHALLCROSS, HERBERT LEX IV
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:LEX
Last Name:SHALLCROSS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6012 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1643
Mailing Address - Country:US
Mailing Address - Phone:215-487-0904
Mailing Address - Fax:215-487-3716
Practice Address - Street 1:6012 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1643
Practice Address - Country:US
Practice Address - Phone:215-487-0904
Practice Address - Fax:215-487-3716
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst