Provider Demographics
NPI:1265002455
Name:GJELHAUG, SHELBY LANAE (COTA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LANAE
Last Name:GJELHAUG
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:
Other - Last Name:CALHOUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:5947 138TH ST NE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-4486
Mailing Address - Country:US
Mailing Address - Phone:612-849-1505
Mailing Address - Fax:
Practice Address - Street 1:5947 138TH ST NE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-4486
Practice Address - Country:US
Practice Address - Phone:612-849-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202222224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant