Provider Demographics
NPI:1902498314
Name:SHELBY, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:SHELBY
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 1:300 INTERNATIONAL PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3625
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:5328 LANIER ISLANDS PKWY STE UNIT101
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-9071
Practice Address - Country:US
Practice Address - Phone:470-655-1970
Practice Address - Fax:470-655-1048
Is Sole Proprietor?:No
Enumeration Date:2021-02-07
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-22-59437103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst