Provider Demographics
NPI:1669839742
Name:SHELLEY, TARA (ATC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:973 OLD MILTON RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-6154
Mailing Address - Country:US
Mailing Address - Phone:904-392-9518
Mailing Address - Fax:
Practice Address - Street 1:105 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-2960
Practice Address - Country:US
Practice Address - Phone:864-200-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer