Healthcare Provider Details

I. General information

NPI: 1366684086
Provider Name (Legal Business Name): STERLING JEREL SHORES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2009
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 JOURNEY WAY
VALPARAISO IN
46383-0078
US

IV. Provider business mailing address

6654 W 158TH LN
LOWELL IN
46356-4407
US

V. Phone/Fax

Practice location:
  • Phone: 192-554-3782
  • Fax:
Mailing address:
  • Phone: 219-798-2597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number31004741A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT00004190
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: