Provider Demographics
NPI:1912037722
Name:HERTEL, SHELLY A (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:A
Last Name:HERTEL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 W GOODMAN DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7426
Mailing Address - Country:US
Mailing Address - Phone:623-512-7005
Mailing Address - Fax:
Practice Address - Street 1:3904 W GOODMAN DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7426
Practice Address - Country:US
Practice Address - Phone:623-512-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4637235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ114186Medicaid