Healthcare Provider Details

I. General information

NPI: 1720438427
Provider Name (Legal Business Name): BENJAMIN WHITNEY SHELBURN M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 VILLA RIDGE PKWY
LAWRENCEVILLE GA
30044-2314
US

IV. Provider business mailing address

828 VILLA RIDGE PKWY
LAWRENCEVILLE GA
30044-2314
US

V. Phone/Fax

Practice location:
  • Phone: 803-873-1319
  • Fax:
Mailing address:
  • Phone: 803-873-1319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP009255
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: