Provider Demographics
NPI:1083029938
Name:HERRON, SHAQUAIL (COTA)
Entity Type:Individual
Prefix:
First Name:SHAQUAIL
Middle Name:
Last Name:HERRON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46218-4675
Mailing Address - Country:US
Mailing Address - Phone:317-993-9025
Mailing Address - Fax:
Practice Address - Street 1:2564 FOX POINTE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-3181
Practice Address - Country:US
Practice Address - Phone:812-372-0950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-29
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002643A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant