Provider Demographics
NPI:1184294571
Name:HEDLUND, SHELBY R
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:R
Last Name:HEDLUND
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 1:102 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2842
Mailing Address - Country:US
Mailing Address - Phone:208-882-3012
Mailing Address - Fax:
Practice Address - Street 1:102 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2842
Practice Address - Country:US
Practice Address - Phone:208-882-3012
Practice Address - Fax:208-882-0396
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4427225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist