Provider Demographics
NPI:1144774191
Name:SHUPP, BAILEE (PT)
Entity Type:Individual
Prefix:
First Name:BAILEE
Middle Name:
Last Name:SHUPP
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 LONGO DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-2901
Mailing Address - Country:US
Mailing Address - Phone:218-230-3393
Mailing Address - Fax:
Practice Address - Street 1:2206 LONGO DR
Practice Address - Street 2:SUITE 211
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-2901
Practice Address - Country:US
Practice Address - Phone:218-230-3393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist