Provider Demographics
NPI:1336824689
Name:O'DELL-BROCK, SHELLEY DENISE (DAC)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:DENISE
Last Name:O'DELL-BROCK
Suffix:
Gender:F
Credentials:DAC
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:DENISE
Other - Last Name:O'DELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:335 W WESCOTT DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-5626
Mailing Address - Country:US
Mailing Address - Phone:602-697-1962
Mailing Address - Fax:
Practice Address - Street 1:4611 E SHEA BLVD STE 180
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-4258
Practice Address - Country:US
Practice Address - Phone:602-697-1962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-000936171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist