Provider Demographics
NPI:1891449765
Name:GOODMAN, SHANNON H (OT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:H
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:HAGERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:230 CLEARFIELD AVE STE 124
Mailing Address - Street 2:
Mailing Address - City:VA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1832
Mailing Address - Country:US
Mailing Address - Phone:757-321-3300
Mailing Address - Fax:757-321-3330
Practice Address - Street 1:733 VOLVO PKWY STE 300
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1610
Practice Address - Country:US
Practice Address - Phone:757-321-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119009349225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist