Provider Demographics
NPI:1891783890
Name:SHULL, ROBERT ALAN (CCC-A)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ALAN
Last Name:SHULL
Suffix:
Gender:M
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10212 CHERRY TREE TER
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-9432
Mailing Address - Country:US
Mailing Address - Phone:937-885-0491
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:88 MDG/SGCXL
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5546
Practice Address - Country:US
Practice Address - Phone:937-257-9280
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK186231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist