=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841718509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELBY PORTER PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2017
-----------------------------------------------------
Last Update Date | 09/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10450 W MCDOWELL RD STE 102
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85392-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-846-7614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4728 N 15TH ST APT 106
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85014-3720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-520-1341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 13164PT
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------