Individual
JERRY LEE SHIELDS JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
COTA
Contact information
Practice address
512 CRESCENT DR, TROY, OH 45373-2718
(937) 546-4204
Mailing address
512 CRESCENT DR, TROY, OH 45373-2718
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
OTA04502
OH
Other
Enumeration date
11/21/2012
Last updated
11/21/2012
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