Provider Demographics
NPI:1215561733
Name:MODJESKI, SHANNON VICTORIA (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:VICTORIA
Last Name:MODJESKI
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:VICTORIA
Other - Last Name:MODJESKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:2185 NE 106TH AVE APT 3411
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-8291
Mailing Address - Country:US
Mailing Address - Phone:971-533-4658
Mailing Address - Fax:
Practice Address - Street 1:13333 SW 68TH PKWY
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-9196
Practice Address - Country:US
Practice Address - Phone:503-352-0240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR434200225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist