Provider Demographics
NPI:1801342050
Name:SHELLEY, BRYAN DAVID
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:DAVID
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 SPRINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-2236
Mailing Address - Country:US
Mailing Address - Phone:330-606-8769
Mailing Address - Fax:
Practice Address - Street 1:4201 SPRINGDALE RD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-2236
Practice Address - Country:US
Practice Address - Phone:330-606-8769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33632255A2300X
OHUC2277822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer