Provider Demographics
NPI:1588995005
Name:ANDERSON, SHELLEY VICKY (OT)
Entity type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:VICKY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02901-1119
Mailing Address - Country:US
Mailing Address - Phone:401-457-1580
Mailing Address - Fax:401-831-0500
Practice Address - Street 1:2 DUDLEY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3248
Practice Address - Country:US
Practice Address - Phone:401-457-2158
Practice Address - Fax:401-457-2198
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10010225X00000X
RI292225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist