Provider Demographics
NPI:1013033745
Name:ELY, SHANNON LEIGH (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEIGH
Last Name:ELY
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 MAPLERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-6512
Mailing Address - Country:US
Mailing Address - Phone:704-777-9925
Mailing Address - Fax:
Practice Address - Street 1:831 MCDOW DR
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2415
Practice Address - Country:US
Practice Address - Phone:803-326-3116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1413225200000X
NC1401225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant