Provider Demographics
NPI:1376644021
Name:SHELLENBERGER, HOLLY LOUISE (MPT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LOUISE
Last Name:SHELLENBERGER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:LOUISE
Other - Last Name:BICKELHAUPT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:203 STATE ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1403
Mailing Address - Country:US
Mailing Address - Phone:315-393-2024
Mailing Address - Fax:315-393-2025
Practice Address - Street 1:203 STATE ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1403
Practice Address - Country:US
Practice Address - Phone:315-393-2024
Practice Address - Fax:315-393-2025
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA9648Medicare PIN