Provider Demographics
NPI:1942558846
Name:HOLLY, SHAQUEALA
Entity Type:Individual
Prefix:
First Name:SHAQUEALA
Middle Name:
Last Name:HOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAQUEALA
Other - Middle Name:
Other - Last Name:LOWERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5005 BANTRY DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1531
Mailing Address - Country:US
Mailing Address - Phone:313-778-5844
Mailing Address - Fax:
Practice Address - Street 1:18285 E 10 MILE RD
Practice Address - Street 2:SUITE. 100
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5802
Practice Address - Country:US
Practice Address - Phone:586-774-5774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007660225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist