Provider Demographics
NPI:1649409830
Name:DIBIASE, SHELLY ANN (PT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:DIBIASE
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 1:1519 132ND ST SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-7203
Mailing Address - Country:US
Mailing Address - Phone:425-357-9380
Mailing Address - Fax:425-357-9382
Practice Address - Street 1:1519 132ND ST SE
Practice Address - Street 2:SUITE A
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-7203
Practice Address - Country:US
Practice Address - Phone:425-337-9556
Practice Address - Fax:425-357-9186
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-653225100000X
WAPT 00006177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0284484OtherL & I
WA0284518OtherL & I
WA0284489OtherL & I
WA0284524OtherL & I
WA0284489OtherL & I
WA0284484OtherL & I
WA0284518OtherL & I
WAG8904900Medicare PIN
WAG8904388Medicare PIN