Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant |
NPI | 1003372574 |
---|---|
Provider Name | Shelby Liles |
First Address | Odessa, MO 64076-6121 |
Second Address | Blue Springs, MO 64014-2503 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2019 |
Last Update Date | 20/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
UNSURE | (05) | MO |