Healthcare Provider Details

I. General information

NPI: 1477174647
Provider Name (Legal Business Name): SHELBY NICOLE IMHOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 CLEVELAND AVE
SAN DIEGO CA
92103-7326
US

IV. Provider business mailing address

17448 CAVALCADE CIR
NOBLESVILLE IN
46060-0005
US

V. Phone/Fax

Practice location:
  • Phone: 765-228-7850
  • Fax:
Mailing address:
  • Phone: 765-228-7850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number160311
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: