Provider Demographics
NPI:1164745642
Name:WESLEY, SHANNON (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:WESLEY
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 1:200 NORFLEET DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-1952
Mailing Address - Country:US
Mailing Address - Phone:606-678-5104
Mailing Address - Fax:
Practice Address - Street 1:200 NORFLEET DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-1952
Practice Address - Country:US
Practice Address - Phone:606-678-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYRO178225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist