Provider Demographics
NPI:1063200186
Name:FROST, SHELLEY EILEEN (DPT)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:EILEEN
Last Name:FROST
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:EILEEN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:21529 MAPLE GLEN DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-8700
Mailing Address - Country:US
Mailing Address - Phone:574-250-5089
Mailing Address - Fax:
Practice Address - Street 1:2222 RIETH BLVD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5868
Practice Address - Country:US
Practice Address - Phone:574-875-9616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010981A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist