Provider Demographics
NPI:1083180806
Name:MILLER, SHANNON MARIE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 GORDON TER
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1708
Mailing Address - Country:US
Mailing Address - Phone:845-820-5599
Mailing Address - Fax:
Practice Address - Street 1:1406 KINGS HWY
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10918-3009
Practice Address - Country:US
Practice Address - Phone:845-827-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023028225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist