Provider Demographics
NPI:1083004329
Name:PERSOHN, SHAY LEE
Entity Type:Individual
Prefix:
First Name:SHAY
Middle Name:LEE
Last Name:PERSOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5048 CHOCTAW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-7658
Mailing Address - Country:US
Mailing Address - Phone:812-639-2727
Mailing Address - Fax:
Practice Address - Street 1:651 S STATE ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-2552
Practice Address - Country:US
Practice Address - Phone:317-736-6414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005468A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist