Provider Demographics
NPI:1780061697
Name:RUSSELL, SHANNON RAYE (OTR/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAYE
Last Name:RUSSELL
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 1:905 S RIPPLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057
Mailing Address - Country:US
Mailing Address - Phone:732-915-8254
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:UNIT 98
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-792-3192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116015225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist