Healthcare Provider Details

I. General information

NPI: 1598712820
Provider Name (Legal Business Name): CHANDRA SHIRLEY PT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21395 JOHN MILLESS DR SUITE 600
ROGERS MN
55374-4402
US

IV. Provider business mailing address

21395 JOHN MILLESS DR SUITE 600
ROGERS MN
55374-4402
US

V. Phone/Fax

Practice location:
  • Phone: 763-428-2589
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1821
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8362
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: