Provider Demographics
NPI:1063792851
Name:SHELLEY, GINA LEE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:LEE
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 CLAYTON ROAD
Mailing Address - Street 2:SSM REHABILITATION HOSPITAL
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117
Mailing Address - Country:US
Mailing Address - Phone:314-768-5338
Mailing Address - Fax:314-768-5208
Practice Address - Street 1:210 SUMMIT RIDGE PL
Practice Address - Street 2:
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-0907
Practice Address - Country:US
Practice Address - Phone:636-244-2134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01413235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist