Provider Demographics
NPI:1124395736
Name:ABBOTT, SHANNON R
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:ABBOTT
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 1:2408 S BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-6236
Mailing Address - Country:US
Mailing Address - Phone:906-364-0507
Mailing Address - Fax:
Practice Address - Street 1:2408 S BELMONT ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-6236
Practice Address - Country:US
Practice Address - Phone:906-364-0507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist