Provider Demographics
NPI:1407390362
Name:CASTANEDA, SHELLY (LMT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:CASTANEDA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 S ELM ST UNIT 116
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3970
Mailing Address - Country:US
Mailing Address - Phone:971-221-2728
Mailing Address - Fax:
Practice Address - Street 1:1655 S ELM ST UNIT 116
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3970
Practice Address - Country:US
Practice Address - Phone:971-221-2728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17677225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist