=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871707190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLY ANN ZELLNER CTRS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20400 COLONEL GLENN RD
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72210-5323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-821-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 56 WATERSIDE CV
-----------------------------------------------------
City | MAUMELLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72113-5833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-425-3681
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225800000X
-----------------------------------------------------
Taxonomy Name | Recreation Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------