Provider Demographics
NPI:1316131113
Name:WIESEL, SHELLEY (OTR)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:WIESEL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4609 GRAPE RD
Mailing Address - Street 2:SUITE B-7
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-2649
Mailing Address - Country:US
Mailing Address - Phone:574-360-8132
Mailing Address - Fax:888-370-2324
Practice Address - Street 1:4609 GRAPE RD
Practice Address - Street 2:STE B-7
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2649
Practice Address - Country:US
Practice Address - Phone:574-360-8132
Practice Address - Fax:888-370-2324
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003555A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200876300Medicaid
IN200876300Medicaid