Provider Demographics
NPI:1497096176
Name:MATHERS, SHANA LOREN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:LOREN
Last Name:MATHERS
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 1:2050 TILDEN AVE
Mailing Address - Street 2:BOX 1000
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-3613
Mailing Address - Country:US
Mailing Address - Phone:315-797-3114
Mailing Address - Fax:315-624-0474
Practice Address - Street 1:2050 TILDEN AVE
Practice Address - Street 2:BOX 1000
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-3613
Practice Address - Country:US
Practice Address - Phone:315-797-3114
Practice Address - Fax:315-624-0474
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017558-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00313539Medicaid
NY01815443Medicaid
NY00313539Medicaid
NY334526Medicare Oscar/Certification