Provider Demographics
NPI:1497960637
Name:THARP, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:THARP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 QUALITY ROW
Mailing Address - Street 2:
Mailing Address - City:WATSON
Mailing Address - State:MO
Mailing Address - Zip Code:64496-8410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1531 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:MOUND CITY
Practice Address - State:MO
Practice Address - Zip Code:64470-1610
Practice Address - Country:US
Practice Address - Phone:660-442-5477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004001983225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist