Provider Demographics
NPI:1831745546
Name:WEED, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WEED
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:W6444 TWO MILE RD
Mailing Address - Street 2:
Mailing Address - City:PORTERFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54159-9343
Mailing Address - Country:US
Mailing Address - Phone:715-923-7374
Mailing Address - Fax:
Practice Address - Street 1:101 1ST ST
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1117
Practice Address - Country:US
Practice Address - Phone:920-834-4575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-18
Last Update Date:2019-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant