Provider Demographics
NPI:1023417102
Name:NOVEGROD, SHANA (OT)
Entity type:Individual
Prefix:MS
First Name:SHANA
Middle Name:
Last Name:NOVEGROD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21615 HAWTHORNE BOULEVARD
Mailing Address - Street 2:#200
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21615 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6668
Practice Address - Country:US
Practice Address - Phone:310-371-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4624225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist