Provider Demographics
NPI:1003880402
Name:YOUNG, SHANNON M (OT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:YOUNG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4400
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-4400
Mailing Address - Country:US
Mailing Address - Phone:605-622-5000
Mailing Address - Fax:605-622-5255
Practice Address - Street 1:305 S STATE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4527
Practice Address - Country:US
Practice Address - Phone:605-622-5000
Practice Address - Fax:605-622-5255
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND945208100000X
SD0286225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDCG3429OtherRAILROAD MEDICARE
ND26336OtherBLUE SHIELD
ND50997Medicaid
NDN711736Medicare PIN
NDCG3429Medicare PIN
NDN711736Medicare Oscar/Certification