Provider Demographics
NPI:1558072165
Name:FREDERICK, SHELLEY CANNON
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:CANNON
Last Name:FREDERICK
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 1:2496 RICKER ROAD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79916
Mailing Address - Country:US
Mailing Address - Phone:915-742-9558
Mailing Address - Fax:915-742-2363
Practice Address - Street 1:2496 RICKER ROAD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79916
Practice Address - Country:US
Practice Address - Phone:915-742-9558
Practice Address - Fax:915-742-2363
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17-043221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist