Provider Demographics
NPI:1609305408
Name:BROWN, SHELLY ELAINE (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ELAINE
Last Name:BROWN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 MYSTIC VALLEY PKWY APT 415
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5733
Mailing Address - Country:US
Mailing Address - Phone:503-484-6080
Mailing Address - Fax:
Practice Address - Street 1:409 LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-0933
Practice Address - Country:US
Practice Address - Phone:781-647-9976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR377983225X00000X
MA14642225XM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist