Basic Information
| Provider Information | |||||||||
| NPI: | 1306812540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELLENBERGER | ||||||||
| FirstName: | SYLVIA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3780 EISENHOWER PKWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312060800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786335500 | ||||||||
| FaxNumber: | 4787843550 | ||||||||
| Practice Location | |||||||||
| Address1: | 3780 EISENHOWER PKWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312060800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786335550 | ||||||||
| FaxNumber: | 4787843550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 04/01/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | GA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 000238268C | 05 | GA | MEDICAID | 680015751 | 01 | GA | RAILROAD MCR - HSCG | OTHER |