Provider Demographics
NPI:1770037640
Name:NEWCOMB, SHANNON MARIE (COTA/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:NEWCOMB
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 1:111 SAVANNAH DAWN CT
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-6451
Mailing Address - Country:US
Mailing Address - Phone:502-428-1320
Mailing Address - Fax:
Practice Address - Street 1:111 SAVANNAH DAWN CT
Practice Address - Street 2:
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-6451
Practice Address - Country:US
Practice Address - Phone:502-428-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY164370224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant