Provider Demographics
NPI:1972707073
Name:GOLDSMITH, SHANNON MARIE (OTR)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:GOLDSMITH
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:PO BOX 1800
Mailing Address - Street 2:4830 DAVID DR.
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-1800
Mailing Address - Country:US
Mailing Address - Phone:804-693-6303
Mailing Address - Fax:
Practice Address - Street 1:6099 T C WALKER RD
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4403
Practice Address - Country:US
Practice Address - Phone:804-693-7880
Practice Address - Fax:804-693-5203
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003932225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist