Provider Demographics
NPI:1871861922
Name:WYATT, SHELLEY NICOLE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:NICOLE
Last Name:WYATT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 REACH DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-8646
Mailing Address - Country:US
Mailing Address - Phone:205-253-2887
Mailing Address - Fax:
Practice Address - Street 1:3057 LORNA RD STE 220
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35216-4518
Practice Address - Country:US
Practice Address - Phone:205-978-9939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2857225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist