Provider Demographics
NPI:1366458705
Name:DUKES, SHANNON TROY (OTRL CHT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:TROY
Last Name:DUKES
Suffix:
Gender:M
Credentials:OTRL CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 W 38TH AVE STE 106B
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4341
Mailing Address - Country:US
Mailing Address - Phone:303-953-3163
Mailing Address - Fax:303-245-0726
Practice Address - Street 1:8550 W 38TH AVE STE 106B
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4341
Practice Address - Country:US
Practice Address - Phone:303-953-3163
Practice Address - Fax:303-245-0726
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002896225XH1200X
AK1276225XH1200X
MD1022608225XH1200X
CA1051100600225XH1200X
1051100600225XH1200X
OR1022608225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
8862498Medicare PIN