Provider Demographics
NPI:1871376350
Name:SHACKELFORD, MICHAEL TOREY (OTR/L)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TOREY
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25100 W INDIAN RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ANDALE
Mailing Address - State:KS
Mailing Address - Zip Code:67001-9741
Mailing Address - Country:US
Mailing Address - Phone:316-617-0660
Mailing Address - Fax:
Practice Address - Street 1:9920 E HARRY ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-5008
Practice Address - Country:US
Practice Address - Phone:316-265-4295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1701301225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist