Provider Demographics
NPI:1194483925
Name:SHIMABUKURO, KELLY (MSOT, OTR)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHIMABUKURO
Suffix:
Gender:F
Credentials:MSOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ADAMS TER
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-4048
Mailing Address - Country:US
Mailing Address - Phone:862-200-0300
Mailing Address - Fax:
Practice Address - Street 1:560 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-1024
Practice Address - Country:US
Practice Address - Phone:908-233-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01011800225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist