Provider Demographics
NPI:1891336921
Name:HOOPER, SHELBY RAE
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:RAE
Last Name:HOOPER
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 55189
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-0189
Mailing Address - Country:US
Mailing Address - Phone:219-628-5565
Mailing Address - Fax:
Practice Address - Street 1:3520 INDUSTRIAL AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7376
Practice Address - Country:US
Practice Address - Phone:907-290-6395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKRBT-19-100373106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician