Provider Demographics
NPI:1003338302
Name:PIECE OUT
Entity Type:Organization
Organization Name:PIECE OUT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MOT, OTR/L
Authorized Official - Phone:405-627-9325
Mailing Address - Street 1:19454 PIONEER WAY
Mailing Address - Street 2:
Mailing Address - City:CASHION
Mailing Address - State:OK
Mailing Address - Zip Code:73016-5500
Mailing Address - Country:US
Mailing Address - Phone:405-627-9325
Mailing Address - Fax:866-486-4825
Practice Address - Street 1:19454 PIONEER WAY
Practice Address - Street 2:
Practice Address - City:CASHION
Practice Address - State:OK
Practice Address - Zip Code:73016-5500
Practice Address - Country:US
Practice Address - Phone:405-627-9325
Practice Address - Fax:866-486-4825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1269225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200267230BMedicaid