Provider Demographics
NPI:1326530098
Name:STANLEY, SHANNON ALEXANDRA (MHSOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ALEXANDRA
Last Name:STANLEY
Suffix:
Gender:F
Credentials:MHSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 WALTHALL ST NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-2623
Mailing Address - Country:US
Mailing Address - Phone:912-293-5869
Mailing Address - Fax:
Practice Address - Street 1:341 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2120
Practice Address - Country:US
Practice Address - Phone:404-341-4282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006272225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist