Provider Demographics
NPI:1134258478
Name:MELLOWS, JOAN SHEPHERD (PT)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:SHEPHERD
Last Name:MELLOWS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:ELAINE
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:3920 ATLAS AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-1552
Mailing Address - Country:US
Mailing Address - Phone:510-482-4074
Mailing Address - Fax:
Practice Address - Street 1:5700 TELEGRAPH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1710
Practice Address - Country:US
Practice Address - Phone:510-204-1788
Practice Address - Fax:510-658-2231
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 13295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist