Provider Demographics
NPI:1619094737
Name:ULLOM, SHELLEY
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:ULLOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5741 INDIANOLA AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2772
Mailing Address - Country:US
Mailing Address - Phone:317-466-1000
Mailing Address - Fax:317-466-2000
Practice Address - Street 1:4740 KINGSWAY DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1521
Practice Address - Country:US
Practice Address - Phone:317-466-1000
Practice Address - Fax:317-466-2000
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004195A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist