Provider Demographics
NPI:1245569375
Name:MAYES, SHELLY L (PT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:MAYES
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 1:1405 MARY LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-2029
Mailing Address - Country:US
Mailing Address - Phone:417-861-5562
Mailing Address - Fax:
Practice Address - Street 1:7540 N 19TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7967
Practice Address - Country:US
Practice Address - Phone:417-861-5562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-20
Last Update Date:2009-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007018573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist