Provider Demographics
NPI:1205393774
Name:DECK, SHANNON (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DECK
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 1:30907 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-3826
Mailing Address - Country:US
Mailing Address - Phone:610-790-9522
Mailing Address - Fax:
Practice Address - Street 1:301 OCEAN VIEW BLVD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1269
Practice Address - Country:US
Practice Address - Phone:302-645-4664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
DEU1-0001866225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist