Provider Demographics
NPI:1750435897
Name:NIELSON, SHELLY (MA)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:NIELSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3291 E HAMPTON LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-6522
Mailing Address - Country:US
Mailing Address - Phone:480-659-9799
Mailing Address - Fax:
Practice Address - Street 1:1084 W. SAN TAN HILLS
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242
Practice Address - Country:US
Practice Address - Phone:480-888-7515
Practice Address - Fax:480-655-6137
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1787235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ872293OtherAHCCCS