Basic Information
| Provider Information | |||||||||
| NPI: | 1841396926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNOODLE | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | ATR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3116 GLOUCHESTER AVE. | ||||||||
| Address2: | #110 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480842729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488163226 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4646 JOHN R | ||||||||
| Address2: | JOHN D DINGELL VAMC 553/11G-PM | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
| FaxNumber: | 3135761246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 221700000X | 99-107 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist |
No ID Information.