Provider Demographics
NPI:1104328608
Name:SIDDALL, SHARI (COTA/L-CLT)
Entity type:Individual
Prefix:
First Name:SHARI
Middle Name:
Last Name:SIDDALL
Suffix:
Gender:F
Credentials:COTA/L-CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 N 45 1/2 RD
Mailing Address - Street 2:
Mailing Address - City:MANTON
Mailing Address - State:MI
Mailing Address - Zip Code:49663-9436
Mailing Address - Country:US
Mailing Address - Phone:616-402-9089
Mailing Address - Fax:
Practice Address - Street 1:1105 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-935-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant