Provider Demographics
NPI:1508256728
Name:MANIGAULT, SHANNON R (COTA/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:MANIGAULT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:R
Other - Last Name:DICKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-2945
Mailing Address - Country:US
Mailing Address - Phone:928-502-7811
Mailing Address - Fax:928-502-7818
Practice Address - Street 1:400 W 5TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-2945
Practice Address - Country:US
Practice Address - Phone:928-502-7811
Practice Address - Fax:928-502-7818
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6063224Z00000X
FLOTA13855-18960224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant