Provider Demographics
NPI:1326426214
Name:WALL, SHANNON (COTA/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CANTERBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-1861
Mailing Address - Country:US
Mailing Address - Phone:901-596-2633
Mailing Address - Fax:
Practice Address - Street 1:33 CANTERBERRY CIR
Practice Address - Street 2:
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-1861
Practice Address - Country:US
Practice Address - Phone:901-596-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant