Provider Demographics
NPI:1124274758
Name:EALY, SHARI L (MMT)
Entity type:Individual
Prefix:
First Name:SHARI
Middle Name:L
Last Name:EALY
Suffix:
Gender:F
Credentials:MMT
Other - Prefix:
Other - First Name:SHARILYNN
Other - Middle Name:E
Other - Last Name:MCGAREY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:1040 SIEVERT ST
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:IN
Mailing Address - Zip Code:46304-1308
Mailing Address - Country:US
Mailing Address - Phone:517-420-2550
Mailing Address - Fax:
Practice Address - Street 1:1040 SIEVERT ST
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:IN
Practice Address - Zip Code:46304-1308
Practice Address - Country:US
Practice Address - Phone:517-420-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIN/A225700000X
IN32002449A224Z00000X
IL057003828224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN32002449AOtherSTATE OF INDIANA