Provider Demographics
NPI:1689451460
Name:MANIBUSAN, SHANELL L (COTA)
Entity Type:Individual
Prefix:
First Name:SHANELL
Middle Name:L
Last Name:MANIBUSAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9235 SOLDIER RD
Mailing Address - Street 2:
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-1617
Mailing Address - Country:US
Mailing Address - Phone:210-885-0500
Mailing Address - Fax:
Practice Address - Street 1:2729 KING ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-4008
Practice Address - Country:US
Practice Address - Phone:703-836-8838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002889224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant