Provider Demographics
NPI:1740701630
Name:ANDERSON, SHELBY (BA)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3143 ESSEX RD
Mailing Address - Street 2:
Mailing Address - City:TOBYHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18466-8222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:193 MARKET ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5409
Practice Address - Country:US
Practice Address - Phone:570-846-0455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician