Provider Demographics
NPI:1083899355
Name:SHANNON, MOLLY S (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:S
Last Name:SHANNON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 EXECUTIVE CENTER DR STE 105
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8823
Mailing Address - Country:US
Mailing Address - Phone:704-566-2899
Mailing Address - Fax:704-566-2862
Practice Address - Street 1:5501 EXECUTIVE CENTER DR STE 105
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8823
Practice Address - Country:US
Practice Address - Phone:704-566-2899
Practice Address - Fax:704-566-2862
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2472225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist