Provider Demographics
NPI:1114135787
Name:SHORK, STEPHEN JOHN (COTA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:SHORK
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20-42 PHILLIPS RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:CT
Mailing Address - Zip Code:06351-7000
Mailing Address - Country:US
Mailing Address - Phone:860-376-5424
Mailing Address - Fax:
Practice Address - Street 1:59 HARRINGTON CT
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1207
Practice Address - Country:US
Practice Address - Phone:860-537-2339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000919224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant