Healthcare Provider Details

I. General information

NPI: 1891371936
Provider Name (Legal Business Name): LYDIA SHAMOON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYDIA M PETROS

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 W MAPLE RD
WEST BLOOMFIELD MI
48322-3013
US

IV. Provider business mailing address

1339 AZALEA LN
WATERFORD MI
48327-4413
US

V. Phone/Fax

Practice location:
  • Phone: 248-325-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: