Provider Demographics
NPI:1417089723
Name:SHUMBOPOISSANT, MONIKA (OTR)
Entity Type:Individual
Prefix:
First Name:MONIKA
Middle Name:
Last Name:SHUMBOPOISSANT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MONIKA
Other - Middle Name:
Other - Last Name:SHUMBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA
Mailing Address - Street 1:1763 S STREAM RD
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-8710
Mailing Address - Country:US
Mailing Address - Phone:605-430-9361
Mailing Address - Fax:
Practice Address - Street 1:2224 AVE A
Practice Address - Street 2:PALM VIEW REHABILITATION & HEALTH CARE CENTER
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367
Practice Address - Country:US
Practice Address - Phone:605-430-9361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205620224Z00000X
CT000330224Z00000X
CT002512225X00000X
VT0720000441225X00000X
WY636225X00000X
MT941225X00000X
WAOT00004270225X00000X
AZ3573225X00000X
MA09345225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist