Basic Information
| Provider Information | |||||||||
| NPI: | 1316248446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTTS | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | HICKS | ||||||||
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| Credential: | CCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13834 WEEPING WILLOW WAY | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322246897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047533650 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 76 OSPREY VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | AMELIA ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320344962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044911701 | ||||||||
| FaxNumber: | 9044911702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2010 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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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 | 235Z00000X | SZ 5021 | FL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SA 11251 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.