Provider Demographics
NPI:1841403995
Name:SHAFIE, SHANNON SHABNAM (OTR)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SHABNAM
Last Name:SHAFIE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 COBBLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1754
Mailing Address - Country:US
Mailing Address - Phone:925-487-0997
Mailing Address - Fax:
Practice Address - Street 1:1640 REDSTONE CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7605
Practice Address - Country:US
Practice Address - Phone:888-800-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0797225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist