Provider Demographics
NPI:1932579828
Name:WEATHERS, SHELLY LEANN
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:LEANN
Last Name:WEATHERS
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:PO BOX 51322
Mailing Address - Street 2:C-3
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-5622
Mailing Address - Country:US
Mailing Address - Phone:843-670-1777
Mailing Address - Fax:
Practice Address - Street 1:4323 OLD MILL RD STE B
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1117
Practice Address - Country:US
Practice Address - Phone:270-777-9283
Practice Address - Fax:270-777-9283
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-16-24711103K00000X
SC103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst