Provider Demographics
NPI:1417669714
Name:SHELLEY, KEVIN SCOTT (OTR)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:SCOTT
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 SEDGEBROOK CT APT 303
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-7347
Mailing Address - Country:US
Mailing Address - Phone:434-616-1779
Mailing Address - Fax:
Practice Address - Street 1:2050 LANGHORNE RD STE 103
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-0002
Practice Address - Country:US
Practice Address - Phone:434-845-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004986225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist