Provider Demographics
NPI:1598712820
Name:SHIRLEY, CHANDRA (PT, ATC)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21395 JOHN MILLESS DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-4402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21395 JOHN MILLESS DR
Practice Address - Street 2:SUITE 600
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4402
Practice Address - Country:US
Practice Address - Phone:763-428-2589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18212255A2300X
MN8362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer