Healthcare Provider Details

I. General information

NPI: 1376115147
Provider Name (Legal Business Name): SHELBY BULLOCK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELBY WILLIAMS PTA

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 VETERANS RD
WARRENSBURG MO
64093-8294
US

IV. Provider business mailing address

800 S MAIN ST
CLINTON MO
64735-2624
US

V. Phone/Fax

Practice location:
  • Phone: 660-543-5064
  • Fax:
Mailing address:
  • Phone: 660-525-3028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2016037538
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: