Provider Demographics
NPI:1275503153
Name:HOLT, SHANNON (OT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:HOLT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3528 WADE AVENUE
Mailing Address - Street 2:#139
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-4048
Mailing Address - Country:US
Mailing Address - Phone:919-782-5954
Mailing Address - Fax:919-859-9444
Practice Address - Street 1:2418 BLUE RIDGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6480
Practice Address - Country:US
Practice Address - Phone:919-782-5954
Practice Address - Fax:919-859-9444
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3358225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13729OtherBLUE CROSS BLUE SHIELD
NC5947795OtherAETNA
NCD9498OtherMEDCOST
NC5947795OtherAETNA