Basic Information
Provider Information | |||||||||
NPI: | 1194049437 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOERTZEN | ||||||||
FirstName: | SHELBY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S., CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4263 W BELMONT AVE | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937225810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5597091348 | ||||||||
FaxNumber: | 5592740223 | ||||||||
Practice Location | |||||||||
Address1: | 1150 W FAIRVIEW ST | ||||||||
Address2: |   | ||||||||
City: | COLFAX | ||||||||
State: | WA | ||||||||
PostalCode: | 991119580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5093974603 | ||||||||
FaxNumber: | 5093979214 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2010 | ||||||||
LastUpdateDate: | 03/16/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | LL 60123648 | WA | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.