Provider Demographics
NPI:1225479058
Name:DAVIDOVICH, SHELLY MARIE (OTR/L, CPAM)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:DAVIDOVICH
Suffix:
Gender:F
Credentials:OTR/L, CPAM
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:MARIE
Other - Last Name:WASIELEWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1200 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7659
Mailing Address - Country:US
Mailing Address - Phone:770-844-3200
Mailing Address - Fax:
Practice Address - Street 1:1200 NORTHSIDE FORSYTH DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7659
Practice Address - Country:US
Practice Address - Phone:770-844-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OT13549225XH1200X
GAOT006418225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand