Provider Demographics
NPI:1821523093
Name:DAVIES, SHELLY (PTA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:DAVIES
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 1:2208 N PICKETT ST
Mailing Address - Street 2:APT 203
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1064
Mailing Address - Country:US
Mailing Address - Phone:904-624-5190
Mailing Address - Fax:
Practice Address - Street 1:8111 TIS WELL DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3211
Practice Address - Country:US
Practice Address - Phone:703-348-7571
Practice Address - Fax:703-780-6438
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603980225200000X
MDA4539225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant