Provider Demographics
NPI:1598897399
Name:SHERIDAN SHOCKLEY, DEE ANNE (OTR)
Entity Type:Individual
Prefix:
First Name:DEE
Middle Name:ANNE
Last Name:SHERIDAN SHOCKLEY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:DEE
Other - Middle Name:ANNE
Other - Last Name:SHERIDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:1610 E. SUNSHINE ST.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:1610 E. SUNSHINE ST.
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:423-238-7217
Practice Address - Fax:423-238-3473
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000152769225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
45417076OtherBCBS KC
MOMA4370053OtherMEDICARE PTAN
MOR26000003Medicare PIN
MOR21000003Medicare PIN
MOMA1009009Medicare PIN
MO45417026OtherBCBS
MO45417016OtherBCBS