Provider Demographics
NPI:1881769990
Name:ALLIS, SHELLY MARIE (PT)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:ALLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:RACHELLE
Other - Middle Name:MARIE
Other - Last Name:ALLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 2638
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-2638
Mailing Address - Country:US
Mailing Address - Phone:805-473-7499
Mailing Address - Fax:805-473-7494
Practice Address - Street 1:271 FIVE CITIES DR
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3009
Practice Address - Country:US
Practice Address - Phone:805-473-7499
Practice Address - Fax:805-473-7494
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 14733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT147330OtherBLUE SHIELD PIN
183834100OtherUS DEPT OF LABOR
CAPT147330Medicaid
CAPT147330OtherBLUE CROSS PIN
183834100OtherUS DEPT OF LABOR
CAOPT147330OtherBLUE SHIELD PIN