Provider Demographics
NPI:1598025710
Name:FLANIGAN, SHELLY LYNN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:LYNN
Last Name:FLANIGAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:LYNN
Other - Last Name:FLANIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:170 ISLAND VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-6456
Mailing Address - Country:US
Mailing Address - Phone:618-204-1624
Mailing Address - Fax:
Practice Address - Street 1:170 ISLAND VIEW DR
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6456
Practice Address - Country:US
Practice Address - Phone:618-204-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003350224Z00000X
CAOTA3657224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant