Provider Demographics
NPI:1801113667
Name:SHELLARD, NICOLE JANELLE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JANELLE
Last Name:SHELLARD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 SYMPHONY DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755
Mailing Address - Country:US
Mailing Address - Phone:516-209-7618
Mailing Address - Fax:
Practice Address - Street 1:5225 NESCONSET HWY
Practice Address - Street 2:SUITE # 30
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-473-4284
Practice Address - Fax:631-331-2204
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012229225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist