Provider Demographics
NPI:1366451510
Name:SHELLEY, RANDALL (PT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4310 LONDONDERRY RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5300
Practice Address - Country:US
Practice Address - Phone:717-782-2343
Practice Address - Fax:717-782-2360
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003222L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPT003222LOtherSTATE LICENSE