Provider Demographics
NPI:1114950755
Name:SHILTS-MARESH, DONNA JEAN (OTR)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:JEAN
Last Name:SHILTS-MARESH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13601 S UNION HALL RD
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-9757
Mailing Address - Country:US
Mailing Address - Phone:503-866-3304
Mailing Address - Fax:503-632-8581
Practice Address - Street 1:13601 S UNION HALL RD
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-9757
Practice Address - Country:US
Practice Address - Phone:503-866-3304
Practice Address - Fax:503-632-8581
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000586225XP0200X
OR586225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR158669Medicaid
OR158669Medicaid