Provider Demographics
NPI:1902170533
Name:SHELLEY, CONNIE RENEE (MS PT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:RENEE
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:RENEE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:800-944-9782
Mailing Address - Fax:610-438-2046
Practice Address - Street 1:1147 S 3RD ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-3472
Practice Address - Country:US
Practice Address - Phone:269-684-9470
Practice Address - Fax:269-684-9477
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist