Provider Demographics
NPI:1184782906
Name:HICKMAN, SHELLEY ISENBERG (OTRL)
Entity type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:ISENBERG
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MRS
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:ISENBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTRL
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444
Mailing Address - Country:US
Mailing Address - Phone:850-258-6366
Mailing Address - Fax:850-522-8022
Practice Address - Street 1:5441 NEHI RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404
Practice Address - Country:US
Practice Address - Phone:850-258-6366
Practice Address - Fax:850-522-8022
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT2238225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist