Provider Demographics
NPI:1982322772
Name:MISS SHANNON S THERAPY 4 KIDZ LLC
Entity Type:Organization
Organization Name:MISS SHANNON S THERAPY 4 KIDZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:K
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:702-970-9242
Mailing Address - Street 1:2449 N TENAYA WAY UNIT 34991
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-9995
Mailing Address - Country:US
Mailing Address - Phone:702-970-9242
Mailing Address - Fax:702-829-5857
Practice Address - Street 1:2449 N TENAYA WAY UNIT 34991
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9995
Practice Address - Country:US
Practice Address - Phone:702-970-9242
Practice Address - Fax:702-829-5857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-17
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003402345Medicaid