Healthcare Provider Details

I. General information

NPI: 1306108873
Provider Name (Legal Business Name): GREGORY MICHAEL SHAHUM PHD, MHA, OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GOSSMAN RD
SOUTHERN PINES NC
28387-2281
US

IV. Provider business mailing address

11022 DAVID STONE DR
CHAPEL HILL NC
27517-7415
US

V. Phone/Fax

Practice location:
  • Phone: 910-246-1000
  • Fax:
Mailing address:
  • Phone: 570-677-0274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number8304
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number003443
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number001929
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: