Provider Demographics
NPI:1255911392
Name:KELLY, SHANNON ELIZABETH (OTR/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:KELLY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BRIELLE AVE
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-5732
Mailing Address - Country:US
Mailing Address - Phone:609-703-5411
Mailing Address - Fax:
Practice Address - Street 1:1336 BELMONT AVE # 502
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-4500
Practice Address - Country:US
Practice Address - Phone:410-546-2894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09273246Z00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist