Provider Demographics
NPI:1316248446
Name:BOTTS, SHELLEY HICKS (CCC/SLP)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:HICKS
Last Name:BOTTS
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 1:13834 WEEPING WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-6897
Mailing Address - Country:US
Mailing Address - Phone:904-753-3650
Mailing Address - Fax:
Practice Address - Street 1:76 OSPREY VILLAGE DR
Practice Address - Street 2:
Practice Address - City:AMELIA ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32034-4962
Practice Address - Country:US
Practice Address - Phone:904-491-1701
Practice Address - Fax:904-491-1702
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ 5021235Z00000X
FLSA 11251235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist