Provider Demographics
NPI:1407149503
Name:SARGENT, SHANE (OTR)
Entity Type:Individual
Prefix:MS
First Name:SHANE
Middle Name:
Last Name:SARGENT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 RYON CIR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16929-9418
Mailing Address - Country:US
Mailing Address - Phone:607-368-7949
Mailing Address - Fax:
Practice Address - Street 1:7787 STATE ROUTE 417
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:NY
Practice Address - Zip Code:14801-9504
Practice Address - Country:US
Practice Address - Phone:607-359-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013373-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist