MEDICARE: MS. SHAELENE IBBETSON MS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	LL00003839	WA

General Provider Information

NPI Number	:	1851591945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHAELENE IBBETSON MS CCC-SLP

Provider Business Mailing Address
First Line	:	5001 CALIFORNIA AVE SW APT 608
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98136-1292
Country	:	US
Telephone Number	:	206-793-8350
Fax Number	:

Provider Business Practice Location Address
First Line	:	5001 CALIFORNIA AVE SW APT 608
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98136-1292
Country	:	US
Telephone Number	:	206-938-3507
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	07/18/2007

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