Provider Demographics
NPI:1225468762
Name:MOORE, SHELLEY
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:
Last Name:MOORE
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 1:5211 MARSH RD
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1106
Mailing Address - Country:US
Mailing Address - Phone:517-319-1383
Mailing Address - Fax:517-318-0258
Practice Address - Street 1:5211 MARSH RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1106
Practice Address - Country:US
Practice Address - Phone:517-319-1383
Practice Address - Fax:517-318-0258
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-20
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000626225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant