Provider Demographics
NPI:1659490233
Name:MARTIN, SHELLI MARIE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:SHELLI
Middle Name:MARIE
Last Name:MARTIN
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 1:2013 MONA CT
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-1024
Mailing Address - Country:US
Mailing Address - Phone:304-638-5410
Mailing Address - Fax:
Practice Address - Street 1:590 POPLAR FORK RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9434
Practice Address - Country:US
Practice Address - Phone:304-757-7826
Practice Address - Fax:304-757-8861
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000707225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant