Provider Demographics
NPI:1477083327
Name:DALE, SHELLEY LYNN
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:LYNN
Last Name:DALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S CARROLL BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-7416
Mailing Address - Country:US
Mailing Address - Phone:972-251-3945
Mailing Address - Fax:
Practice Address - Street 1:525 S. CARROLL BLVD STE 202
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-7620
Practice Address - Country:US
Practice Address - Phone:972-251-3945
Practice Address - Fax:972-251-3945
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT122627225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist