Provider Demographics
NPI:1295215481
Name:SHIBEN, KELSEY (OTR)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:SHIBEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 WILLIAM MILLS DR
Mailing Address - Street 2:
Mailing Address - City:STANARDSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22973-3055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 WILLIAM MILLS DR
Practice Address - Street 2:
Practice Address - City:STANARDSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22973-3055
Practice Address - Country:US
Practice Address - Phone:434-985-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119007035225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119007035OtherOTR LICENSE