Provider Demographics
NPI:1396721452
Name:SHIVELY, MIRIAM D (OTR,L,CHT)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:D
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:OTR,L,CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 CENTRAL AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-6848
Mailing Address - Country:US
Mailing Address - Phone:501-318-4263
Mailing Address - Fax:501-318-1007
Practice Address - Street 1:1801 CENTRAL AVE
Practice Address - Street 2:SUITE H
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-6848
Practice Address - Country:US
Practice Address - Phone:501-318-4263
Practice Address - Fax:501-318-1007
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR394224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T294Medicare ID - Type Unspecified