Provider Demographics
NPI:1245091289
Name:SHEDLOCK, TIFFANY JOY (MSS, OTR/L, CAPS)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JOY
Last Name:SHEDLOCK
Suffix:
Gender:F
Credentials:MSS, OTR/L, CAPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-4131
Mailing Address - Country:US
Mailing Address - Phone:248-410-3812
Mailing Address - Fax:
Practice Address - Street 1:400 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9225
Practice Address - Country:US
Practice Address - Phone:269-463-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009305225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation