Provider Demographics
NPI:1457786675
Name:CLARK, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 W 132ND AVE
Mailing Address - Street 2:SPC 268
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80234-1499
Mailing Address - Country:US
Mailing Address - Phone:720-495-2942
Mailing Address - Fax:
Practice Address - Street 1:860 W 132ND AVE
Practice Address - Street 2:SPC 268
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-1499
Practice Address - Country:US
Practice Address - Phone:720-495-2942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1072069224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant