Provider Demographics
NPI:1831515337
Name:SHADE, MARY ELIZABETH (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:SHADE
Suffix:
Gender:F
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 1:2000 W STANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2572
Mailing Address - Country:US
Mailing Address - Phone:937-339-5100
Mailing Address - Fax:
Practice Address - Street 1:2000 W STANFIELD RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2572
Practice Address - Country:US
Practice Address - Phone:937-339-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA02370224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant