Provider Demographics
NPI:1932850765
Name:SHANE, MARIAH NICOLE
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:NICOLE
Last Name:SHANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13574 VILLAGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-7689
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13574 VILLAGE PARK DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-7689
Practice Address - Country:US
Practice Address - Phone:407-990-2847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18624224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant