Provider Demographics
NPI:1689181604
Name:DANIELS, SHALA (COTA/L)
Entity type:Individual
Prefix:
First Name:SHALA
Middle Name:
Last Name:DANIELS
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 1:112 S PEMBROKE AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-6349
Mailing Address - Country:US
Mailing Address - Phone:740-683-2289
Mailing Address - Fax:
Practice Address - Street 1:3680 DOLSON CT
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:OH
Practice Address - Zip Code:43112-9721
Practice Address - Country:US
Practice Address - Phone:740-654-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-30
Last Update Date:2017-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA007114224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH105414265-00Medicaid