Provider Demographics
NPI:1184939837
Name:BILLINGSLEY, SHANE JEREMY (DT)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:JEREMY
Last Name:BILLINGSLEY
Suffix:
Gender:M
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 N CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47283-9787
Mailing Address - Country:US
Mailing Address - Phone:812-593-5453
Mailing Address - Fax:812-346-4232
Practice Address - Street 1:604 N CARROLL ST
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:IN
Practice Address - Zip Code:47283-9787
Practice Address - Country:US
Practice Address - Phone:812-593-5453
Practice Address - Fax:812-346-4232
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist