Provider Demographics
NPI:1720285802
Name:SHAKE, RONNETTA FAYE (COTA)
Entity Type:Individual
Prefix:MS
First Name:RONNETTA
Middle Name:FAYE
Last Name:SHAKE
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 1:304 E RACE ST
Mailing Address - Street 2:
Mailing Address - City:ODON
Mailing Address - State:IN
Mailing Address - Zip Code:47562-1420
Mailing Address - Country:US
Mailing Address - Phone:812-636-8530
Mailing Address - Fax:
Practice Address - Street 1:2119 E NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-4507
Practice Address - Country:US
Practice Address - Phone:812-254-3301
Practice Address - Fax:812-257-0039
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000834A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant