Provider Demographics
NPI:1841396926
Name:KNOODLE, SHELLEY LEE (ATR)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:LEE
Last Name:KNOODLE
Suffix:
Gender:F
Credentials:ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 GLOUCHESTER AVE.
Mailing Address - Street 2:#110
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-2729
Mailing Address - Country:US
Mailing Address - Phone:248-816-3226
Mailing Address - Fax:
Practice Address - Street 1:4646 JOHN R
Practice Address - Street 2:JOHN D DINGELL VAMC 553/11G-PM
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-576-1000
Practice Address - Fax:313-576-1246
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99-107221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist