Healthcare Provider Details

I. General information

NPI: 1255495768
Provider Name (Legal Business Name): SHELBY ANDERSON P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 WESTSIDE DR NW SUITE 103
CLEVELAND TN
37312-3699
US

IV. Provider business mailing address

2700 WESTSIDE DR NW SUITE 103
CLEVELAND TN
37312-3699
US

V. Phone/Fax

Practice location:
  • Phone: 423-614-0097
  • Fax:
Mailing address:
  • Phone: 423-614-0097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3272
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: