Provider Demographics
NPI:1689008229
Name:BIRDWELL, SHELLY DENISE (PTA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:DENISE
Last Name:BIRDWELL
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 1:235 PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38256-6437
Mailing Address - Country:US
Mailing Address - Phone:731-363-5752
Mailing Address - Fax:
Practice Address - Street 1:117 HUMMINGBIRD CIR
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:TN
Practice Address - Zip Code:38320-1623
Practice Address - Country:US
Practice Address - Phone:731-584-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-31
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5419225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant