Provider Demographics
NPI:1578829115
Name:SHAMROCK THERAPY SERVICES
Entity Type:Organization
Organization Name:SHAMROCK THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCPATIONAL THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BANTA
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:352-804-0753
Mailing Address - Street 1:2910 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-2768
Mailing Address - Country:US
Mailing Address - Phone:352-804-0753
Mailing Address - Fax:352-620-2272
Practice Address - Street 1:2910 SE 7TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-2768
Practice Address - Country:US
Practice Address - Phone:352-804-0753
Practice Address - Fax:352-620-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL354225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL880196700OtherMEDICAID INDIVIDUAL NUMBER KATHLEEN BANTA
FLZ1623OtherBLUE CROSS BLUE SHIELD
FL881488100OtherMEDICAID GROUP NUMBER SHAMROCK THERAPY SERVICES