=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487398194
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLEY ANN DAVIS NC LMBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2022
-----------------------------------------------------
Last Update Date | 04/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2603 N CROATAN HWY STE B
-----------------------------------------------------
City | KILL DEVIL HILLS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27948-9588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-454-8402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 PORTHOLE CT
-----------------------------------------------------
City | KILL DEVIL HILLS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27948-9370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-454-8402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 02173
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------