Provider Demographics
NPI:1790887438
Name:SHEVENELL, ELISE BLAIR (MS, PT)
Entity Type:Individual
Prefix:MS
First Name:ELISE
Middle Name:BLAIR
Last Name:SHEVENELL
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 COURT SQ
Mailing Address - Street 2:SUITE 345
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108-2503
Mailing Address - Country:US
Mailing Address - Phone:617-742-4897
Mailing Address - Fax:617-742-4899
Practice Address - Street 1:15 COURT SQ
Practice Address - Street 2:SUITE 345
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-2503
Practice Address - Country:US
Practice Address - Phone:617-742-4897
Practice Address - Fax:617-742-4899
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY65801OtherBLUE CROSS - BLUE SHIELD
MASH Y68254Medicare ID - Type Unspecified