Provider Demographics
NPI:1326525783
Name:MAZALUSKY, SHANNON (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MAZALUSKY
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:PA
Mailing Address - Zip Code:18220-5004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:149 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:TAMAQUA
Practice Address - State:PA
Practice Address - Zip Code:18252-4619
Practice Address - Country:US
Practice Address - Phone:570-668-1775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOCO6462L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist