Provider Demographics
NPI:1841718509
Name:PORTER, SHELBY (PT)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:PORTER
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 1:4728 N 15TH ST APT 106
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-3720
Mailing Address - Country:US
Mailing Address - Phone:815-520-1341
Mailing Address - Fax:
Practice Address - Street 1:10450 W MCDOWELL RD STE 102
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4901
Practice Address - Country:US
Practice Address - Phone:626-846-7614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13164PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ13164PTOtherLICENSE