Provider Demographics
NPI:1205429073
Name:HALL, SHANE CARLOS (COTA)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:CARLOS
Last Name:HALL
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 S ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3614
Mailing Address - Country:US
Mailing Address - Phone:610-566-1400
Mailing Address - Fax:
Practice Address - Street 1:318 S ORANGE ST
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3614
Practice Address - Country:US
Practice Address - Phone:610-566-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP008316224ZL0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224ZL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantLow VisionGroup - Single Specialty