Provider Demographics
NPI:1518307099
Name:SHORE, LEANN MARIE (OTD, MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:LEANN
Middle Name:MARIE
Last Name:SHORE
Suffix:
Gender:F
Credentials:OTD, MA, 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:PO BOX 23511
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-0511
Mailing Address - Country:US
Mailing Address - Phone:952-237-5398
Mailing Address - Fax:
Practice Address - Street 1:7432 PARK AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-4462
Practice Address - Country:US
Practice Address - Phone:952-237-5398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101975225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN101975OtherMN LICENSE
MN005572OtherNBCOT