Provider Demographics
NPI:1912002098
Name:VIDAS, SHELLY L (OT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:VIDAS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 HAMMOND ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4328
Mailing Address - Country:US
Mailing Address - Phone:207-992-4042
Mailing Address - Fax:207-992-4043
Practice Address - Street 1:890 HAMMOND ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4328
Practice Address - Country:US
Practice Address - Phone:207-992-4042
Practice Address - Fax:207-992-4043
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT790225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist