Provider Demographics
NPI:1972837599
Name:SHIELDS, KENT C (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:C
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 WELLMAN RD
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14710-9624
Mailing Address - Country:US
Mailing Address - Phone:716-640-2888
Mailing Address - Fax:
Practice Address - Street 1:640 WORTH ST
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-8515
Practice Address - Country:US
Practice Address - Phone:814-664-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP006343224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant