Provider Demographics
NPI:1053825521
Name:SHIREK, DYLAN (OT)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:SHIREK
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 24TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-2903
Mailing Address - Country:US
Mailing Address - Phone:507-251-8117
Mailing Address - Fax:
Practice Address - Street 1:3700 FOSS RD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-4512
Practice Address - Country:US
Practice Address - Phone:612-788-9673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12567225X00000X
MN105537225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist