Provider Demographics
NPI:1467862060
Name:BORGARD, SHANNAN M (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:M
Last Name:BORGARD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 N 17TH ST APT 303
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1737
Mailing Address - Country:US
Mailing Address - Phone:417-631-8943
Mailing Address - Fax:
Practice Address - Street 1:2120 BRYAN VALLEY COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3495
Practice Address - Country:US
Practice Address - Phone:636-240-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014006820225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics