Provider Demographics
NPI:1811593247
Name:NEW, SHANNON WALKER (COTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:WALKER
Last Name:NEW
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:SHAY
Other - Middle Name:
Other - Last Name:NEW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:177 STABLE LN
Mailing Address - Street 2:
Mailing Address - City:STANARDSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22973-3612
Mailing Address - Country:US
Mailing Address - Phone:434-990-1728
Mailing Address - Fax:540-948-4297
Practice Address - Street 1:1 AUTUMN CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:VA
Practice Address - Zip Code:22727-3028
Practice Address - Country:US
Practice Address - Phone:540-948-3054
Practice Address - Fax:540-948-4297
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000722224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant