Provider Demographics
NPI:1619168093
Name:SHELLEY, ROBERT SAMUEL (PTA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:SAMUEL
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 GOLF TERRACE BLVD
Mailing Address - Street 2:UNIT 2
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-0315
Mailing Address - Country:US
Mailing Address - Phone:843-773-8933
Mailing Address - Fax:
Practice Address - Street 1:555 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2617
Practice Address - Country:US
Practice Address - Phone:843-777-2043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1427225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant