Provider Demographics
NPI:1821403098
Name:SHANA CERNY LLC
Entity Type:Organization
Organization Name:SHANA CERNY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CERNY
Authorized Official - Suffix:
Authorized Official - Credentials:OTD
Authorized Official - Phone:605-759-2291
Mailing Address - Street 1:119 N YALE ST
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-2720
Mailing Address - Country:US
Mailing Address - Phone:605-759-2291
Mailing Address - Fax:
Practice Address - Street 1:119 N YALE ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-2720
Practice Address - Country:US
Practice Address - Phone:605-759-2291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0797225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1831473990Medicaid
IA1831473990Medicaid