Provider Demographics
NPI:1720404080
Name:SHAFER, CAROLINE GRACE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:GRACE
Last Name:SHAFER
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 1:3067 NEW WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44818-9358
Mailing Address - Country:US
Mailing Address - Phone:419-569-3490
Mailing Address - Fax:
Practice Address - Street 1:959 HOPLEY AVE
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-3506
Practice Address - Country:US
Practice Address - Phone:419-562-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0040932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer