Provider Demographics
NPI:1720211709
Name:CLEARWATER, SHANNON MARIE (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIE
Last Name:CLEARWATER
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD, OTR/L
Mailing Address - Street 1:701 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SLEEPY HOLLOW
Mailing Address - State:NY
Mailing Address - Zip Code:10591-1020
Mailing Address - Country:US
Mailing Address - Phone:914-366-3717
Mailing Address - Fax:845-366-1312
Practice Address - Street 1:755 N BROADWAY
Practice Address - Street 2:
Practice Address - City:SLEEPY HOLLOW
Practice Address - State:NY
Practice Address - Zip Code:10591-1075
Practice Address - Country:US
Practice Address - Phone:914-366-3717
Practice Address - Fax:314-366-1312
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014797225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03139755Medicaid
NYA400015594Medicare PIN