Provider Demographics
NPI:1689162992
Name:SHAJU, MERITTA
Entity Type:Individual
Prefix:
First Name:MERITTA
Middle Name:
Last Name:SHAJU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 GREEN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-9546
Mailing Address - Country:US
Mailing Address - Phone:734-972-0125
Mailing Address - Fax:
Practice Address - Street 1:440 W RUSSELL ST
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1184
Practice Address - Country:US
Practice Address - Phone:734-429-9401
Practice Address - Fax:734-972-0125
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009359225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty