Provider Demographics
NPI:1952489882
Name:LEICESTER, SHELLY POLNICK (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:POLNICK
Last Name:LEICESTER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 WARREN PKWY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-4274
Mailing Address - Country:US
Mailing Address - Phone:214-618-4301
Mailing Address - Fax:214-618-4302
Practice Address - Street 1:5757 WARREN PKWY
Practice Address - Street 2:SUITE 180
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-4274
Practice Address - Country:US
Practice Address - Phone:214-618-4301
Practice Address - Fax:214-618-4302
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1134518225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB140765Medicare PIN
TX8K9714Medicare UPIN