Provider Demographics
NPI:1427082528
Name:WATERS, SHELLEY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2932 BIRDSONG CIR
Mailing Address - Street 2:
Mailing Address - City:GRIMESLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27837-9525
Mailing Address - Country:US
Mailing Address - Phone:252-717-7924
Mailing Address - Fax:252-757-0663
Practice Address - Street 1:2932 BIRDSONG CIR
Practice Address - Street 2:
Practice Address - City:GRIMESLAND
Practice Address - State:NC
Practice Address - Zip Code:27837-9525
Practice Address - Country:US
Practice Address - Phone:252-717-7924
Practice Address - Fax:252-757-0663
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6730235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1415WOtherBCBS PROVIDER
NC7412499Medicaid