Provider Demographics
NPI:1659317162
Name:DEAN, SHELLEY ANNE I (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANNE
Last Name:DEAN
Suffix:I
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9129 MONROE RD STE 100-105
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-2429
Mailing Address - Country:US
Mailing Address - Phone:704-847-3911
Mailing Address - Fax:
Practice Address - Street 1:9129 MONROE RD
Practice Address - Street 2:SUITE 100-105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-2429
Practice Address - Country:US
Practice Address - Phone:704-847-3911
Practice Address - Fax:704-847-2033
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 103T00000X
SC2890 OT174400000X
NC4306 OTR/L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301435Medicaid
NCB0333OtherMEDCOST
NC138EEOtherBCBS