Provider Demographics
NPI:1568480960
Name:RYAN, SHELLY L (PT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:RYAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:LEIGH
Other - Last Name:LUEBBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1199 S BELT LINE RD
Mailing Address - Street 2:# 140
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-4666
Mailing Address - Country:US
Mailing Address - Phone:972-745-9060
Mailing Address - Fax:
Practice Address - Street 1:1199 S BELT LINE RD
Practice Address - Street 2:# 140
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-4666
Practice Address - Country:US
Practice Address - Phone:972-745-9060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1122919225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T6853OtherBCBS