Provider Demographics
NPI:1104124726
Name:SHANNON, MICHELLE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 KAMEO DR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-5052
Mailing Address - Country:US
Mailing Address - Phone:402-290-4612
Mailing Address - Fax:
Practice Address - Street 1:9220 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2297
Practice Address - Country:US
Practice Address - Phone:402-393-7313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-06
Last Update Date:2011-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE195225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist