Basic Information
| Provider Information | |||||||||
| NPI: | 1952614950 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHADWICK | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | COURTNEY | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 736 CAMBRIDGE ST | ||||||||
| Address2: | DEPARTMENT OF OTOLARNGOLOGY, SMC-8 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021352907 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 S HERLONG AVE STE A | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033281864 | ||||||||
| FaxNumber: | 8033281865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 231H00000X | 12332 | NC | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 936 | MA | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 4070 | SC | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1456498 | 01 | SC | WELLCARE OF SC | OTHER | 19QFR | 01 | NC | BCBSNC | OTHER | SA1792 | 05 | SC | MEDICAID |