Provider Demographics
NPI:1013393917
Name:RANDALL, SHANNON (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 TOWNPARK DR NW STE 300
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5812
Mailing Address - Country:US
Mailing Address - Phone:855-423-6287
Mailing Address - Fax:678-669-1562
Practice Address - Street 1:2030 WINDWARD LN
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-7418
Practice Address - Country:US
Practice Address - Phone:770-535-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006090225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist