Provider Demographics
NPI:1902128085
Name:SMITH, SHELLEY ANN (OTR)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:105 E SYCAMORE ST
Mailing Address - City:CONVERSE
Mailing Address - State:IN
Mailing Address - Zip Code:46919-0475
Mailing Address - Country:US
Mailing Address - Phone:765-395-3482
Mailing Address - Fax:
Practice Address - Street 1:4725 S COLONIAL OAKS DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5341
Practice Address - Country:US
Practice Address - Phone:765-674-9791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004860A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist