Provider Demographics
NPI:1639382831
Name:KNESER, SHANNON L (OTR)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:L
Last Name:KNESER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N162W20069 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037-9278
Mailing Address - Country:US
Mailing Address - Phone:262-677-1571
Mailing Address - Fax:
Practice Address - Street 1:N84W17049 MENOMONEE AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2701
Practice Address - Country:US
Practice Address - Phone:262-255-1180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3552-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40829100Medicaid