Provider Demographics
NPI:1891243325
Name:WILSON, SHANNON (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:LENTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:121 PINEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-1517
Mailing Address - Country:US
Mailing Address - Phone:516-627-1663
Mailing Address - Fax:
Practice Address - Street 1:45 N STATION PLZ
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5033
Practice Address - Country:US
Practice Address - Phone:516-482-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009992225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics