Basic Information
| Provider Information | |||||||||
| NPI: | 1194396499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARE | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRASL | ||||||||
| OtherFirstName: | SHELBY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5718 | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599035718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067560134 | ||||||||
| FaxNumber: | 4063001612 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANACONDA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597112252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065630797 | ||||||||
| FaxNumber: | 4065630796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2021 | ||||||||
| LastUpdateDate: | 03/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTP-PT-LIC-19339 | MT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.