Provider Demographics
NPI:1083811202
Name:HOLMAN, SHANNON LEA (OTRL MED)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEA
Last Name:HOLMAN
Suffix:
Gender:F
Credentials:OTRL MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 WINDING WOODS DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-8081
Mailing Address - Country:US
Mailing Address - Phone:513-677-9508
Mailing Address - Fax:
Practice Address - Street 1:5900 MEADOW CREEK DR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-5641
Practice Address - Country:US
Practice Address - Phone:513-248-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT 004032225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0616533Medicaid