Basic Information
| Provider Information | |||||||||
| NPI: | 1780197004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | SHAYE | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 LOOMIS ST | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021511911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812498639 | ||||||||
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| Practice Location | |||||||||
| Address1: | 932 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | CHELSEA | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021502213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178892250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2017 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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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 | 23063 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.