Provider Demographics
NPI:1588624514
Name:SHELLY, ELIZABETH R (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:SHELLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1634 AVENUE OF THE CITIES
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-4860
Mailing Address - Country:US
Mailing Address - Phone:563-940-2481
Mailing Address - Fax:866-761-7464
Practice Address - Street 1:1634 AVENUE OF THE CITIES
Practice Address - Street 2:SUITE C
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-4860
Practice Address - Country:US
Practice Address - Phone:563-940-2481
Practice Address - Fax:866-761-7464
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011762225100000X
IA03058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216315Medicare PIN