Provider Demographics
NPI:1871587253
Name:SANDBULTE, SHELLEY LYNN (EDD)
Entity type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:LYNN
Last Name:SANDBULTE
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:DR
Other - First Name:SHELLEY
Other - Middle Name:L
Other - Last Name:PEDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDD
Mailing Address - Street 1:2210 S BROWN PL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6582
Mailing Address - Country:US
Mailing Address - Phone:605-332-1700
Mailing Address - Fax:605-336-9031
Practice Address - Street 1:2210 S BROWN PL
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6582
Practice Address - Country:US
Practice Address - Phone:605-332-1700
Practice Address - Fax:605-336-9031
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD311103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6550683Medicaid
SD6550683Medicaid