Provider Demographics
NPI:1629450671
Name:BROCK, SHELBY (PTA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2083 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WI
Mailing Address - Zip Code:54822-9785
Mailing Address - Country:US
Mailing Address - Phone:715-296-4739
Mailing Address - Fax:
Practice Address - Street 1:2083 15TH AVE
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:WI
Practice Address - Zip Code:54822-9785
Practice Address - Country:US
Practice Address - Phone:715-296-4739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2330-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant