Provider Demographics
NPI:1568933976
Name:NOFZ, SHANNON L (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:NOFZ
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41894 COUNTY ROAD 653
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-9469
Mailing Address - Country:US
Mailing Address - Phone:269-986-3518
Mailing Address - Fax:
Practice Address - Street 1:6120 STADIUM DR STE 100
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-3022
Practice Address - Country:US
Practice Address - Phone:269-372-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007762225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588642110Medicaid