Healthcare Provider Details

I. General information

NPI: 1760891915
Provider Name (Legal Business Name): BONNIE SHELTON MS, SLP, CCC-L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 E OAK ST
BROWNSTOWN IL
62418-1302
US

IV. Provider business mailing address

538 E OAK ST
BROWNSTOWN IL
62418-1302
US

V. Phone/Fax

Practice location:
  • Phone: 618-427-5104
  • Fax:
Mailing address:
  • Phone: 618-427-5104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.008431
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: