Provider Demographics
NPI:1386708295
Name:SHIRISHKAR, ARCHANA (OTR)
Entity type:Individual
Prefix:
First Name:ARCHANA
Middle Name:
Last Name:SHIRISHKAR
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 1:38004 FRINGE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-3053
Mailing Address - Country:US
Mailing Address - Phone:248-353-3260
Mailing Address - Fax:248-353-3275
Practice Address - Street 1:26699 W 12 MILE RD
Practice Address - Street 2:STE 202
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1578
Practice Address - Country:US
Practice Address - Phone:242-353-3260
Practice Address - Fax:248-353-3275
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001865225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201001865OtherOCCUPATIONAL THERAPY LICE
MI670F302750OtherBCBSM