Provider Demographics
NPI:1932585809
Name:SHANNON, BETHANY DAWN (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:DAWN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:RODDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:12124 HIGH TECH AVE.
Mailing Address - Street 2:STE. 300
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817
Mailing Address - Country:US
Mailing Address - Phone:800-774-7785
Mailing Address - Fax:877-217-9271
Practice Address - Street 1:4343 OAK GROVE BLVD.
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904
Practice Address - Country:US
Practice Address - Phone:325-942-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209824224Z00000X
NM3267224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant