Provider Demographics
NPI:1659617769
Name:SHELLY, KRISTIN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:
Last Name:SHELLY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:SWEPSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3509 MARCEY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-2912
Mailing Address - Country:US
Mailing Address - Phone:719-502-1285
Mailing Address - Fax:
Practice Address - Street 1:5570 POWERS CENTER PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7100
Practice Address - Country:US
Practice Address - Phone:719-266-6022
Practice Address - Fax:719-277-7217
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25684225100000X
CO11307225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist