Provider Demographics
NPI:1710465547
Name:GWYN, SHANNA NICOLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:NICOLE
Last Name:GWYN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113A OLD SPRING RD
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-8140
Mailing Address - Country:US
Mailing Address - Phone:919-622-4286
Mailing Address - Fax:
Practice Address - Street 1:260 VILLAGE LAKE RD
Practice Address - Street 2:
Practice Address - City:SILER CITY
Practice Address - State:NC
Practice Address - Zip Code:27344-1820
Practice Address - Country:US
Practice Address - Phone:919-742-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11866224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11866OtherNORTH CAROLINA BOARD OF OCCUPATIONAL THERAPY
403214OtherNATIONAL BOARD OF OCCUPATIONAL THERAPY