Provider Demographics
NPI:1952614950
Name:SHADWICK, KELLY COURTNEY (AUD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:COURTNEY
Last Name:SHADWICK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 CAMBRIDGE ST
Mailing Address - Street 2:DEPARTMENT OF OTOLARNGOLOGY, SMC-8
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2817 ROCK MERITT AVE
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-1182
Practice Address - Country:US
Practice Address - Phone:910-907-6982
Practice Address - Fax:803-328-1865
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12332231H00000X
MA936231H00000X
SC4070231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19QFROtherBCBSNC
SC1456498OtherWELLCARE OF SC
SCSA1792Medicaid