Provider Demographics
NPI:1336620475
Name:DITTMAR, SHELLY LEE (PT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:LEE
Last Name:DITTMAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16301 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1104
Mailing Address - Country:US
Mailing Address - Phone:586-263-2480
Mailing Address - Fax:586-263-2179
Practice Address - Street 1:16301 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1104
Practice Address - Country:US
Practice Address - Phone:586-263-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist