Individual
MR. SHANE MICHAEL DISHEAUX
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
COTA
Contact information
Practice address
2827 NORTHGATE BLVD, FORT WAYNE, IN 46835-2903
(260) 492-1498
(260) 492-1674
Mailing address
5305 WOODWAY DR, FORT WAYNE, IN 46835-3676
(260) 492-2027
(260) 492-1674
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
32001345A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1555-656
—
IN
Enumeration date
07/02/2007
Last updated
07/08/2007
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