Provider Demographics
NPI:1811630221
Name:OLIVER SHORTRIDGE, KALI
Entity Type:Individual
Prefix:
First Name:KALI
Middle Name:
Last Name:OLIVER SHORTRIDGE
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 1:1620 NW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-5206
Mailing Address - Country:US
Mailing Address - Phone:954-536-3846
Mailing Address - Fax:
Practice Address - Street 1:613 HAMMONDS LN
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MD
Practice Address - Zip Code:21225-3351
Practice Address - Country:US
Practice Address - Phone:410-636-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA03055224Z00000X
FLOTA17606224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty