Provider Demographics
NPI:1134516586
Name:SHAPE SHIFTERS WELLNESS STUDIO, LLC
Entity Type:Organization
Organization Name:SHAPE SHIFTERS WELLNESS STUDIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRISCOLL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:443-386-0818
Mailing Address - Street 1:3614 OLD MANSE CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4144
Mailing Address - Country:US
Mailing Address - Phone:443-386-0818
Mailing Address - Fax:410-465-5522
Practice Address - Street 1:169 FREDERICK RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4886
Practice Address - Country:US
Practice Address - Phone:443-386-0818
Practice Address - Fax:410-465-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16510174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty