Provider Demographics
NPI:1073706776
Name:SHANNON, SUSAN M (OTR)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:SHANNON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7330 PINE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-8150
Mailing Address - Country:US
Mailing Address - Phone:732-598-3630
Mailing Address - Fax:
Practice Address - Street 1:7985 KNIGHT RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-6427
Practice Address - Country:US
Practice Address - Phone:770-781-4899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-25
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00412900225X00000X
GAOT006602225X00000X
OT006602225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist