Provider Demographics
NPI:1053906081
Name:MADDOX, SHELLY
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13701 E HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:PECULIAR
Mailing Address - State:MO
Mailing Address - Zip Code:64078-9532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1612 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MO
Practice Address - Zip Code:64040-1685
Practice Address - Country:US
Practice Address - Phone:816-258-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTC235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist