Provider Demographics
NPI:1740727080
Name:RUTTER, SHANNON GRACE (MS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:GRACE
Last Name:RUTTER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-6303
Mailing Address - Country:US
Mailing Address - Phone:407-284-0103
Mailing Address - Fax:
Practice Address - Street 1:2608 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-6303
Practice Address - Country:US
Practice Address - Phone:407-284-0103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist