Provider Demographics
NPI:1124029780
Name:PELLER, SHELLY STEIN (PT)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:STEIN
Last Name:PELLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1038
Mailing Address - Fax:
Practice Address - Street 1:1825 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1625
Practice Address - Country:US
Practice Address - Phone:762-235-2700
Practice Address - Fax:706-236-6437
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT001302225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
582308747OtherPHCS
GA754694439AMedicaid
582308747OtherACORDIA
GA754694439CMedicaid
069100OtherBCBS GA
5142439582308747OtherAETNA
21168648367OtherBEECHSTREET
GA754694439BMedicaid
GA754694439DMedicaid
AL890013210Medicaid
582308747OtherUNITED HEALTHCARE
2227530OtherFIRST HEALTH
582308747OtherSTATE HEALTH