Provider Demographics
NPI:1710149786
Name:WAKEM, SHANNON RENAE (OTR, CHT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENAE
Last Name:WAKEM
Suffix:
Gender:F
Credentials:OTR, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-0965
Mailing Address - Country:US
Mailing Address - Phone:503-694-8366
Mailing Address - Fax:503-694-8581
Practice Address - Street 1:8995 SW MILEY RD STE 109
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-5485
Practice Address - Country:US
Practice Address - Phone:503-694-8366
Practice Address - Fax:503-694-8581
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1049473225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297902Medicaid