Provider Demographics
NPI:1770176455
Name:MACMASTER, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MACMASTER
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 1:912 DENTON BLVD NW APT 1903
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1681
Mailing Address - Country:US
Mailing Address - Phone:313-595-6337
Mailing Address - Fax:
Practice Address - Street 1:912 DENTON BLVD NW APT 1903
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1681
Practice Address - Country:US
Practice Address - Phone:313-595-6337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-14
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15575224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant