Provider Demographics
NPI:1497059505
Name:PERRY, SHELLEY ANN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:ANN
Last Name:PERRY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 FLETCHER ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-1402
Mailing Address - Country:US
Mailing Address - Phone:845-294-8301
Mailing Address - Fax:845-294-6384
Practice Address - Street 1:2 FLETCHER ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-1402
Practice Address - Country:US
Practice Address - Phone:845-294-8301
Practice Address - Fax:845-294-6384
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007372-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker