Provider Demographics
NPI:1821579715
Name:NIX, SHANNON D (OTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:NIX
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 W BELT LINE RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-1104
Mailing Address - Country:US
Mailing Address - Phone:972-349-1313
Mailing Address - Fax:
Practice Address - Street 1:318 W BELT LINE RD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-1104
Practice Address - Country:US
Practice Address - Phone:972-349-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214328224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant