Provider Demographics
NPI:1215412200
Name:SHANNON, JOSEPH RYAN
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RYAN
Last Name:SHANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 CARINO CT
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-6375
Mailing Address - Country:US
Mailing Address - Phone:805-674-6978
Mailing Address - Fax:
Practice Address - Street 1:1806 CARINO CT
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-6375
Practice Address - Country:US
Practice Address - Phone:805-674-6978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT-18394225X00000X
MTOTP-OT-LIC-6130225X00000X
IDOT-1974225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist