Provider Demographics
NPI:1770632507
Name:EVENSON, SHANNON (OTR, L)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:EVENSON
Suffix:
Gender:F
Credentials:OTR, L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5201
Mailing Address - Fax:
Practice Address - Street 1:3580 ARCADE ST
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-7135
Practice Address - Country:US
Practice Address - Phone:651-968-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4439-026225X00000X
MN106813225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41066100Medicaid
WI0615 20195Medicare PIN