Healthcare Provider Details

I. General information

NPI: 1134516586
Provider Name (Legal Business Name): SHAPE SHIFTERS WELLNESS STUDIO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 FREDERICK RD
ELLICOTT CITY MD
21043-4886
US

IV. Provider business mailing address

3614 OLD MANSE CT
ELLICOTT CITY MD
21043-4144
US

V. Phone/Fax

Practice location:
  • Phone: 443-386-0818
  • Fax: 410-465-5522
Mailing address:
  • Phone: 443-386-0818
  • Fax: 410-465-5522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16510
License Number StateMD

VIII. Authorized Official

Name: ELLEN DRISCOLL
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: P.T.
Phone: 443-386-0818