Provider Demographics
NPI:1114313459
Name:HATCHEW, SHELLY DENISE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:DENISE
Last Name:HATCHEW
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 1:9099 DODGE RD
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48463-9449
Mailing Address - Country:US
Mailing Address - Phone:810-691-2722
Mailing Address - Fax:
Practice Address - Street 1:9099 DODGE RD
Practice Address - Street 2:
Practice Address - City:OTISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48463-9449
Practice Address - Country:US
Practice Address - Phone:810-691-2722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004412225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant