Provider Demographics
NPI:1598177966
Name:SHELLEY, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 ROSS CLARK CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-3049
Mailing Address - Country:US
Mailing Address - Phone:334-673-2422
Mailing Address - Fax:
Practice Address - Street 1:3118 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-3049
Practice Address - Country:US
Practice Address - Phone:334-673-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH9532251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand