Provider Demographics
NPI:1912957358
Name:DAVIS, SHELLY HENNINK (OTR)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:HENNINK
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 FIRESTONE DR SE
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-8478
Mailing Address - Country:US
Mailing Address - Phone:616-656-0037
Mailing Address - Fax:616-949-5599
Practice Address - Street 1:1111 LEFFINGWELL AVE NE
Practice Address - Street 2:SUITE 210
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6406
Practice Address - Country:US
Practice Address - Phone:616-949-5061
Practice Address - Fax:616-949-5599
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000680225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand