Provider Demographics
NPI:1508840810
Name:SHELLY, SHAWNALEA (OTRL)
Entity Type:Individual
Prefix:
First Name:SHAWNALEA
Middle Name:
Last Name:SHELLY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18150 N ALTERRA PKWY
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85239-4200
Mailing Address - Country:US
Mailing Address - Phone:520-568-5160
Mailing Address - Fax:
Practice Address - Street 1:18150 N ALTERRA PKWY
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85239-4200
Practice Address - Country:US
Practice Address - Phone:520-568-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1653225X00000X
WAOT00003805225X00000X
AZ0779225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275138Medicaid
WA8802893Medicare PIN
OR275138Medicaid