Provider Demographics
NPI:1073094868
Name:FORTIN, SHAWNA LEIGH (COTA)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:LEIGH
Last Name:FORTIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 49TH AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-3705
Mailing Address - Country:US
Mailing Address - Phone:303-659-7758
Mailing Address - Fax:
Practice Address - Street 1:1051 6TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-3278
Practice Address - Country:US
Practice Address - Phone:970-353-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0000146224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty