Provider Demographics
NPI:1669956470
Name:SIACA, SHELLY
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:SIACA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:
Other - Last Name:SIACA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:113 W GREEN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1629
Mailing Address - Country:US
Mailing Address - Phone:682-234-7916
Mailing Address - Fax:
Practice Address - Street 1:113 W GREEN ST STE 100
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76179-1629
Practice Address - Country:US
Practice Address - Phone:682-234-7916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1744P3200X
TX1006201174400000X, 246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist