Provider Demographics
NPI:1215526587
Name:REVORD, SHELLEY LYNN (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:LYNN
Last Name:REVORD
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N KOBS RD
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9762
Mailing Address - Country:US
Mailing Address - Phone:989-310-1963
Mailing Address - Fax:
Practice Address - Street 1:1691 E US 23 STE 4
Practice Address - Street 2:
Practice Address - City:EAST TAWAS
Practice Address - State:MI
Practice Address - Zip Code:48730-9337
Practice Address - Country:US
Practice Address - Phone:989-310-1962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006633235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist