Healthcare Provider Details

I. General information

NPI: 1639034218
Provider Name (Legal Business Name): SHANE HAKE MS, OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3767 DELAWARE AVE
KENMORE NY
14217-1040
US

IV. Provider business mailing address

27 PAVONIA ST
BUFFALO NY
14207-2318
US

V. Phone/Fax

Practice location:
  • Phone: 716-874-6175
  • Fax:
Mailing address:
  • Phone: 585-236-6188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: