Provider Demographics
NPI:1598447492
Name:SHOEMAKER, RIELLY MCKENNA (OTR/L)
Entity Type:Individual
Prefix:
First Name:RIELLY
Middle Name:MCKENNA
Last Name:SHOEMAKER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 W LAKE ST UNIT 3
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-4702
Mailing Address - Country:US
Mailing Address - Phone:248-342-2856
Mailing Address - Fax:
Practice Address - Street 1:22310 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1657
Practice Address - Country:US
Practice Address - Phone:248-342-2856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013225225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist