Provider Demographics
NPI:1811033319
Name:WHITE, SHELLY LEWIS (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:LEWIS
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 W EAGLE TALON TRL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5347
Mailing Address - Country:US
Mailing Address - Phone:828-234-2211
Mailing Address - Fax:
Practice Address - Street 1:25615 N RANCH GATE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-2141
Practice Address - Country:US
Practice Address - Phone:480-502-7726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP8764235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ112477Medicaid