Provider Demographics
NPI:1659187623
Name:SUDDUTH, SHELBY L
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:L
Last Name:SUDDUTH
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 1:620 GERRARD AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NE
Mailing Address - Zip Code:68647-4023
Mailing Address - Country:US
Mailing Address - Phone:217-381-9984
Mailing Address - Fax:
Practice Address - Street 1:620 GERRARD AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NE
Practice Address - Zip Code:68647-4023
Practice Address - Country:US
Practice Address - Phone:217-381-9984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician