Provider Demographics
NPI:1518275924
Name:WALLER, SHELLEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ARNOLD MALL
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-2223
Mailing Address - Country:US
Mailing Address - Phone:636-282-0056
Mailing Address - Fax:636-282-0057
Practice Address - Street 1:4 ARNOLD MALL
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2223
Practice Address - Country:US
Practice Address - Phone:636-282-0056
Practice Address - Fax:636-282-0057
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004682225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist