Provider Demographics
NPI:1740658202
Name:SHADE, JONATHAN PETER (OT)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:PETER
Last Name:SHADE
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3945
Mailing Address - Country:US
Mailing Address - Phone:407-814-0436
Mailing Address - Fax:407-814-0818
Practice Address - Street 1:1509 W ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-2640
Practice Address - Country:US
Practice Address - Phone:407-814-0436
Practice Address - Fax:407-814-0818
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT1641225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist