Provider Demographics
NPI:1134702590
Name:SHELLEY, MARCI
Entity Type:Individual
Prefix:
First Name:MARCI
Middle Name:
Last Name:SHELLEY
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 1:15392 E 700TH AVE
Mailing Address - Street 2:
Mailing Address - City:WATSON
Mailing Address - State:IL
Mailing Address - Zip Code:62473-2314
Mailing Address - Country:US
Mailing Address - Phone:217-343-1505
Mailing Address - Fax:
Practice Address - Street 1:101 TROWBRIDGE RD
Practice Address - Street 2:
Practice Address - City:NEOGA
Practice Address - State:IL
Practice Address - Zip Code:62447-1121
Practice Address - Country:US
Practice Address - Phone:217-343-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004451225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL160004451OtherPHYSICAL THERAPY LICENSE