Provider Demographics
NPI:1770854135
Name:SUTER, SHANNON WARD (MS,OTR/L, CLT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:WARD
Last Name:SUTER
Suffix:
Gender:F
Credentials:MS,OTR/L, CLT
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:THERESE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,OTR/L, CLT
Mailing Address - Street 1:58 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-3307
Mailing Address - Country:US
Mailing Address - Phone:314-346-2856
Mailing Address - Fax:
Practice Address - Street 1:11802 BRINLEY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1089
Practice Address - Country:US
Practice Address - Phone:502-244-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005198A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist