Provider Demographics
NPI:1003938911
Name:ISON, SHANNA MARIE (OTRL)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:MARIE
Last Name:ISON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 S PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2627
Mailing Address - Country:US
Mailing Address - Phone:304-925-1532
Mailing Address - Fax:304-926-8010
Practice Address - Street 1:699 S PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2627
Practice Address - Country:US
Practice Address - Phone:304-925-1532
Practice Address - Fax:304-926-8018
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1156225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist