Provider Demographics
NPI:1922451533
Name:WAFER, SHARAE SHARESE (COTA)
Entity Type:Individual
Prefix:
First Name:SHARAE
Middle Name:SHARESE
Last Name:WAFER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18682 GARFIELD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-1718
Mailing Address - Country:US
Mailing Address - Phone:313-932-3653
Mailing Address - Fax:
Practice Address - Street 1:41215 FOX RUN
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-4803
Practice Address - Country:US
Practice Address - Phone:248-668-8730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007187224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23-5634Medicare PIN