Provider Demographics
NPI:1710463112
Name:PETTERSSON, SHANNON (OTR)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PETTERSSON
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 1:9220 KIRBY DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2534
Mailing Address - Country:US
Mailing Address - Phone:713-383-9700
Mailing Address - Fax:713-383-9795
Practice Address - Street 1:9330 BROADWAY ST STE 312
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7895
Practice Address - Country:US
Practice Address - Phone:713-383-9700
Practice Address - Fax:713-383-9795
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119267225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist