Provider Demographics
NPI:1518577097
Name:GOLDSTON, SHANNON (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:GOLDSTON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 CHRISTINA DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-3425
Mailing Address - Country:US
Mailing Address - Phone:602-738-9790
Mailing Address - Fax:
Practice Address - Street 1:100 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-1926
Practice Address - Country:US
Practice Address - Phone:702-332-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOTA-2543224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty