Provider Demographics
NPI:1104476308
Name:LEE, SHILOH DALLAS
Entity type:Individual
Prefix:
First Name:SHILOH
Middle Name:DALLAS
Last Name:LEE
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 1:651 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-3029
Mailing Address - Country:US
Mailing Address - Phone:765-242-2686
Mailing Address - Fax:
Practice Address - Street 1:651 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-3029
Practice Address - Country:US
Practice Address - Phone:765-242-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002624A225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN32002624AOtherLICENSE NUMBER