Provider Demographics
NPI:1548600828
Name:WALT, SHELLY CHARLENE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:CHARLENE
Last Name:WALT
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 1:4860 MANZANA DR
Mailing Address - Street 2:APT. 210
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911-3015
Mailing Address - Country:US
Mailing Address - Phone:719-459-9789
Mailing Address - Fax:
Practice Address - Street 1:4860 MANZANA DR
Practice Address - Street 2:APT. 210
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911-3015
Practice Address - Country:US
Practice Address - Phone:719-459-9789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0014438225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist