Provider Demographics
NPI:1588900682
Name:GRAHAM, SHELLEY MONTINA (PTA)
Entity type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:MONTINA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17251 LAGUNA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-7740
Mailing Address - Country:US
Mailing Address - Phone:806-499-3766
Mailing Address - Fax:
Practice Address - Street 1:400 RANGER ST
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:TX
Practice Address - Zip Code:79045-2812
Practice Address - Country:US
Practice Address - Phone:806-364-0669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2040400225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant