Provider Demographics
NPI:1578799722
Name:SMITH, SHANNON LYNN (OT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:400 S 43RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5714
Practice Address - Country:US
Practice Address - Phone:425-690-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2021-11-29
Deactivation Date:2018-12-18
Deactivation Code:
Reactivation Date:2019-02-04
Provider Licenses
StateLicense IDTaxonomies
WAOT00002086225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0291600OtherDEPT. OF LABOR AND INDUSTRIES
WA1578799722Medicaid
WAG8906038Medicare PIN