Provider Demographics
NPI:1386941292
Name:HERBOTH, SHELLY RAE
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:RAE
Last Name:HERBOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2868 E 825TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONT
Mailing Address - State:IL
Mailing Address - Zip Code:62411-3554
Mailing Address - Country:US
Mailing Address - Phone:618-483-5493
Mailing Address - Fax:
Practice Address - Street 1:2868 E 825TH AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:IL
Practice Address - Zip Code:62411-3554
Practice Address - Country:US
Practice Address - Phone:618-483-5493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-13
Last Update Date:2011-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist