Provider Demographics
NPI:1790287704
Name:KEARNS, SHANNON S
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:S
Last Name:KEARNS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 WADE CT
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1788
Mailing Address - Country:US
Mailing Address - Phone:314-581-7945
Mailing Address - Fax:
Practice Address - Street 1:1001 S KIRKWOOD RD STE 150
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-7251
Practice Address - Country:US
Practice Address - Phone:314-821-7554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002005500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist