Healthcare Provider Details

I. General information

NPI: 1588995005
Provider Name (Legal Business Name): SHELLEY VICKY ANDERSON OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST SUITE 200
PROVIDENCE RI
02905-3248
US

IV. Provider business mailing address

PO BOX 1119
PROVIDENCE RI
02901-1119
US

V. Phone/Fax

Practice location:
  • Phone: 401-457-2158
  • Fax: 401-457-2198
Mailing address:
  • Phone: 401-457-1580
  • Fax: 401-831-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number10010
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number292
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: