Provider Demographics
NPI:1528545415
Name:TEESDALE, SHELLY GERMAINE (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:GERMAINE
Last Name:TEESDALE
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2063 WINSTON VIEW DR NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49319-7947
Mailing Address - Country:US
Mailing Address - Phone:616-862-8900
Mailing Address - Fax:
Practice Address - Street 1:4450 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3633
Practice Address - Country:US
Practice Address - Phone:616-949-5140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007005225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist