Provider Demographics
NPI:1659906618
Name:SHIRAEF, ELLEN ELISABETH (OTR)
Entity Type:Individual
Prefix:MISS
First Name:ELLEN
Middle Name:ELISABETH
Last Name:SHIRAEF
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 1:4665 WATERBROOKE XING
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-3566
Mailing Address - Country:US
Mailing Address - Phone:423-838-8207
Mailing Address - Fax:
Practice Address - Street 1:762 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-2376
Practice Address - Country:US
Practice Address - Phone:678-783-6815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007676225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist