Provider Demographics
NPI:1215222492
Name:SHATTUCK, SHELLANE N (DPT)
Entity Type:Individual
Prefix:
First Name:SHELLANE
Middle Name:N
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HAZARD AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4521
Mailing Address - Country:US
Mailing Address - Phone:860-265-2571
Mailing Address - Fax:860-265-2574
Practice Address - Street 1:145 HAZARD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4521
Practice Address - Country:US
Practice Address - Phone:860-265-2571
Practice Address - Fax:860-265-2574
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19528225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT009353OtherSTATE OF CONNECTICUT LICENSE