Provider Demographics
NPI:1417498387
Name:RUSSELL, SHELLEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39210 LIVE OAK DR
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-6664
Mailing Address - Country:US
Mailing Address - Phone:985-510-0282
Mailing Address - Fax:
Practice Address - Street 1:39210 LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-6664
Practice Address - Country:US
Practice Address - Phone:985-510-0282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3637225X00000X
LAOTT.Z12304225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics