Provider Demographics
NPI:1275620270
Name:HOLMAN, SHANNON (OTR/L, BCP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HOLMAN
Suffix:
Gender:F
Credentials:OTR/L, BCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2449 N TENAYA WAY UNIT 34991
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-9995
Mailing Address - Country:US
Mailing Address - Phone:702-970-9242
Mailing Address - Fax:
Practice Address - Street 1:2449 N TENAYA WAY UNIT 34991
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9995
Practice Address - Country:US
Practice Address - Phone:702-970-9242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0046225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003402345Medicaid
NV382617193OtherEIN