Provider Demographics
NPI:1972701506
Name:ROSE, SHELLEY JEAN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:JEAN
Last Name:ROSE
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 1:2907 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-2316
Mailing Address - Country:US
Mailing Address - Phone:360-210-5171
Mailing Address - Fax:
Practice Address - Street 1:310 4TH ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674-8488
Practice Address - Country:US
Practice Address - Phone:360-225-9443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8193225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant