Provider Demographics
NPI:1063523397
Name:CLEVERDON, SHELLENE SUE (OT-L)
Entity type:Individual
Prefix:MRS
First Name:SHELLENE
Middle Name:SUE
Last Name:CLEVERDON
Suffix:
Gender:F
Credentials:OT-L
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 200
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:MT
Mailing Address - Zip Code:59914
Mailing Address - Country:US
Mailing Address - Phone:406-260-5692
Mailing Address - Fax:406-849-6501
Practice Address - Street 1:42468 JUNIPER SHORES LANE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:MT
Practice Address - Zip Code:59914
Practice Address - Country:US
Practice Address - Phone:406-260-5692
Practice Address - Fax:406-849-6501
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT523225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0347293Medicaid
MT660990OtherBCBS
MT0347293Medicaid