Provider Demographics
NPI:1588212161
Name:PETERSON, SHANNON LYLE (OTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYLE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S HILLANDALE DR
Mailing Address - Street 2:
Mailing Address - City:EAST FLAT ROCK
Mailing Address - State:NC
Mailing Address - Zip Code:28726-2610
Mailing Address - Country:US
Mailing Address - Phone:828-696-5949
Mailing Address - Fax:
Practice Address - Street 1:1870 PISGAH DR
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-3759
Practice Address - Country:US
Practice Address - Phone:828-693-9796
Practice Address - Fax:828-693-1321
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8145224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty