Provider Demographics
NPI:1285146142
Name:PETERSEN, SHELBY MICHELLE (SLP-A)
Entity type:Individual
Prefix:MISS
First Name:SHELBY
Middle Name:MICHELLE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CALAIS CV
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-9575
Mailing Address - Country:US
Mailing Address - Phone:501-940-2335
Mailing Address - Fax:
Practice Address - Street 1:10310 W MARKHAM ST STE 205
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-1579
Practice Address - Country:US
Practice Address - Phone:501-406-7910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR18-0072355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR18-007OtherARKANSAS BOARD OF EXAMINERS IN SPEECH PATHOLOGY AND AUDIOLOGY