Provider Demographics
NPI:1912456419
Name:SHIRLEY, ANNETTE L (OTA06630)
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:L
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:OTA06630
Other - Prefix:MISS
Other - First Name:ANNETTE
Other - Middle Name:L
Other - Last Name:POLLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:24 VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-1423
Mailing Address - Country:US
Mailing Address - Phone:234-817-1363
Mailing Address - Fax:
Practice Address - Street 1:30325 BAINBRIDGE RD
Practice Address - Street 2:SUITE A-5
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2295
Practice Address - Country:US
Practice Address - Phone:440-498-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-25
Last Update Date:2016-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA06630171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor