Provider Demographics
NPI:1760103709
Name:LEON, SHANNON ROSE (OTR)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:ROSE
Last Name:LEON
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 1:4054 N SHERIDAN RD APT 1E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2083
Mailing Address - Country:US
Mailing Address - Phone:563-449-4075
Mailing Address - Fax:
Practice Address - Street 1:1957 W DICKENS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3934
Practice Address - Country:US
Practice Address - Phone:773-789-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist