Provider Demographics
NPI:1962244863
Name:GILLEN, SHELBY GRACE (AUD)
Entity type:Individual
Prefix:DR
First Name:SHELBY
Middle Name:GRACE
Last Name:GILLEN
Suffix:
Gender:
Credentials:AUD
Other - Prefix:MS
Other - First Name:SHELBY
Other - Middle Name:GRACE
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19110 MONTGOMERY VILLAGE AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-3706
Mailing Address - Country:US
Mailing Address - Phone:301-977-6317
Mailing Address - Fax:301-977-8503
Practice Address - Street 1:19110 MONTGOMERY VILLAGE AVE STE 120
Practice Address - Street 2:
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-3706
Practice Address - Country:US
Practice Address - Phone:301-977-6317
Practice Address - Fax:301-977-8503
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001975231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist