Provider Demographics
NPI:1316668148
Name:SHIRLEY, FRED R (PT)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:R
Last Name:SHIRLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6843 N CITRUS AVE
Mailing Address - Street 2:BLDG 2, UNIT T
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34428
Mailing Address - Country:US
Mailing Address - Phone:352-322-6093
Mailing Address - Fax:352-794-3243
Practice Address - Street 1:2780 N FLORIDA AVE UNIT 7-8
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:FL
Practice Address - Zip Code:34442-4390
Practice Address - Country:US
Practice Address - Phone:352-322-6093
Practice Address - Fax:352-897-6093
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PT13162225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist