Provider Demographics
NPI:1801496963
Name:HUMPHREY, SHANNA (OT/CLT)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:OT/CLT
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:
Other - Last Name:NOTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:PO BOX 7377
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-7377
Mailing Address - Country:US
Mailing Address - Phone:541-633-7535
Mailing Address - Fax:541-706-9036
Practice Address - Street 1:2041 NE WILLIAMSON CT STE B
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3941
Practice Address - Country:US
Practice Address - Phone:541-633-7535
Practice Address - Fax:541-706-9036
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1058897225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist