Basic Information
| Provider Information | |||||||||
| NPI: | 1215222492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHATTUCK | ||||||||
| FirstName: | SHELLANE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 HAZARD AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060824521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602652571 | ||||||||
| FaxNumber: | 8602652574 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 HAZARD AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060824521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602652571 | ||||||||
| FaxNumber: | 8602652574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2011 | ||||||||
| LastUpdateDate: | 05/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 19528 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 009353 | 01 | CT | STATE OF CONNECTICUT LICENSE | OTHER |