Provider Demographics
NPI:1699289066
Name:WATKINS, SHELLY (OTR/L)
Entity type:Individual
Prefix:MISS
First Name:SHELLY
Middle Name:
Last Name:WATKINS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13973 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5403
Mailing Address - Country:US
Mailing Address - Phone:734-855-4490
Mailing Address - Fax:
Practice Address - Street 1:3751 2ND AVE APT 1A
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1751
Practice Address - Country:US
Practice Address - Phone:313-443-6925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI5201013297225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician