Provider Demographics
NPI:1508243015
Name:SHOOK, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:SHOOK
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 1:3484 ENTERPRISE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27295-9286
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3905 CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8479
Practice Address - Country:US
Practice Address - Phone:336-766-9158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9589225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist