Provider Demographics
NPI:1245442771
Name:SHELBY, KIMBERLY DAWN (MCD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:SHELBY
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:MCKAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MCD CCC SLP
Mailing Address - Street 1:105 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72417-8831
Mailing Address - Country:US
Mailing Address - Phone:501-291-7222
Mailing Address - Fax:
Practice Address - Street 1:105 N OAK ST
Practice Address - Street 2:
Practice Address - City:BROOKLAND
Practice Address - State:AR
Practice Address - Zip Code:72417
Practice Address - Country:US
Practice Address - Phone:870-935-7809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP663235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121751721Medicaid