Provider Demographics
NPI:1174064299
Name:IMBER, SHIRLEY ANN (LAT, ATC)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:ANN
Last Name:IMBER
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:ANN
Other - Last Name:TOMTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:1021 VALLEY BLUFF DR APT 15
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-2831
Mailing Address - Country:US
Mailing Address - Phone:419-205-8586
Mailing Address - Fax:
Practice Address - Street 1:11661 W STATE ROUTE 163
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:OH
Practice Address - Zip Code:43449-1278
Practice Address - Country:US
Practice Address - Phone:621-641-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
FLAL53842255A2300X
OHAT0061812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program