Provider Demographics
NPI:1225076573
Name:STEPHENS, SHELLY BALES (PT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:BALES
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:LOUISE
Other - Last Name:BALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 306393
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6393
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-373-7116
Practice Address - Street 1:502 N MARKET ST STE 102
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-4438
Practice Address - Country:US
Practice Address - Phone:423-634-1922
Practice Address - Fax:423-634-1924
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5722225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446652Medicare ID - Type UnspecifiedGROUP NUMBER
TN3646995Medicare PIN
TN3156797OtherBCBST - GROUP NUMBER
TN0446652Medicaid
TN5441624Medicaid