Provider Demographics
NPI:1073254637
Name:RYBERG, SHANNON (MSOTR/L, CLT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RYBERG
Suffix:
Gender:F
Credentials:MSOTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WINSLOW RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02556-2838
Mailing Address - Country:US
Mailing Address - Phone:617-620-0586
Mailing Address - Fax:
Practice Address - Street 1:114 WINSLOW RD
Practice Address - Street 2:
Practice Address - City:NORTH FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02556-2838
Practice Address - Country:US
Practice Address - Phone:617-620-0586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10253225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10253OtherDIVISION OF PROFESSIONAL LICENSURE BOARD OF ALLIED HEALTH PROFESSIONALS
279133OtherNATIONAL BOARD OF OCCUPATIONAL THERAPY