Provider Demographics
NPI:1669832747
Name:HOLLAND, SHELLEY R (CTRS)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:R
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 E BEACH BLVD # 5128
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-6259
Mailing Address - Country:US
Mailing Address - Phone:228-214-3319
Mailing Address - Fax:
Practice Address - Street 1:730 E BEACH BLVD # 5128
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-6259
Practice Address - Country:US
Practice Address - Phone:228-214-3319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS66563225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist