Provider Demographics
NPI:1760603385
Name:LONG, SHANNON DAWN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:DAWN
Last Name:LONG
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 LOSEE ST.
Mailing Address - Street 2:PO BOX 274
Mailing Address - City:CYGNET
Mailing Address - State:OH
Mailing Address - Zip Code:43413-0274
Mailing Address - Country:US
Mailing Address - Phone:419-655-2970
Mailing Address - Fax:
Practice Address - Street 1:11080 E. GYPSY LANE RD.
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402
Practice Address - Country:US
Practice Address - Phone:419-352-0259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA.02940224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant