Provider Demographics
NPI:1730537077
Name:WHITEHEAD, SHELLEY (COTA/L)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5157 US HIGHWAY 61 67
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-1606
Mailing Address - Country:US
Mailing Address - Phone:314-392-8082
Mailing Address - Fax:
Practice Address - Street 1:5157 US HIGHWAY 61 67
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-1606
Practice Address - Country:US
Practice Address - Phone:314-392-8082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015001890224Z00000X
IL057.004242224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant