Provider Demographics
NPI:1598947558
Name:MONGRAIN, SHELLEY RAE (PT)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:RAE
Last Name:MONGRAIN
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 1:220 E HELENA AVE
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-2004
Mailing Address - Country:US
Mailing Address - Phone:509-430-7995
Mailing Address - Fax:
Practice Address - Street 1:220 E HELENA AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-2004
Practice Address - Country:US
Practice Address - Phone:509-430-7995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist