Provider Demographics
NPI:1518366418
Name:KAMINSKI, SHANNON (OTD, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:KAMINSKI
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:LASSITER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:780 S APOLLO BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1402
Mailing Address - Country:US
Mailing Address - Phone:321-432-2572
Mailing Address - Fax:321-768-2489
Practice Address - Street 1:780 S APOLLO BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1402
Practice Address - Country:US
Practice Address - Phone:321-432-2572
Practice Address - Fax:321-768-2489
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14989225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016078300Medicaid