Provider Demographics
NPI:1558574426
Name:GOEDDEL, SHELLEY DANIELLE (PT PHYSICAL THERAPIS)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:DANIELLE
Last Name:GOEDDEL
Suffix:
Gender:F
Credentials:PT PHYSICAL THERAPIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 GRANTWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-2014
Mailing Address - Country:US
Mailing Address - Phone:314-843-0046
Mailing Address - Fax:
Practice Address - Street 1:8747 BIG BEN BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119
Practice Address - Country:US
Practice Address - Phone:314-843-0046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01282225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist