Provider Demographics
NPI:1144903162
Name:HOMAN, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:HOMAN
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 1:816 W DOUGLAS AVE
Mailing Address - Street 2:1/2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650
Mailing Address - Country:US
Mailing Address - Phone:217-617-6966
Mailing Address - Fax:
Practice Address - Street 1:816 W DOUGLAS AVE
Practice Address - Street 2:1/2
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650
Practice Address - Country:US
Practice Address - Phone:217-617-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2578188103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool