Provider Demographics
NPI:1881873933
Name:GAUL, SHELLEY KAY (PTA)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:KAY
Last Name:GAUL
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 1:5403 VICTORIA AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3925
Mailing Address - Country:US
Mailing Address - Phone:563-327-0132
Mailing Address - Fax:
Practice Address - Street 1:1101 W 9TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-3732
Practice Address - Country:US
Practice Address - Phone:563-324-1621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001210225200000X
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant