Provider Demographics
NPI:1801566260
Name:WIREMAN, SHANNON KAY (COTA/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KAY
Last Name:WIREMAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 W KOZAK DR
Mailing Address - Street 2:
Mailing Address - City:WHEATFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46392-7373
Mailing Address - Country:US
Mailing Address - Phone:219-964-8262
Mailing Address - Fax:
Practice Address - Street 1:10820 PARK PL
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8630
Practice Address - Country:US
Practice Address - Phone:219-351-5214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001594A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant