Provider Demographics
NPI:1538616750
Name:STILLMAN, SHELLY R (MA,PLPC)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:R
Last Name:STILLMAN
Suffix:
Gender:F
Credentials:MA,PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2747
Mailing Address - Country:US
Mailing Address - Phone:636-795-5468
Mailing Address - Fax:
Practice Address - Street 1:567 MADISON ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2747
Practice Address - Country:US
Practice Address - Phone:636-795-5468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016031782101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2016031782Medicaid