Provider Demographics
NPI:1851384168
Name:MOATS, SHELLEY R (AUD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:R
Last Name:MOATS
Suffix:
Gender:F
Credentials:AUD
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 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:1050 E MARKET ST STE 1
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1874
Practice Address - Country:US
Practice Address - Phone:502-588-9587
Practice Address - Fax:502-588-9580
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0465231H00000X
KY100528237600000X
KY101740231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50009966OtherPASSPORT
IN200864840Medicaid
KY70001268Medicaid
IN200864840Medicaid