Provider Demographics
NPI:1154521078
Name:MAYSE, SHANNON ANNE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:ANNE
Last Name:MAYSE
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 1:501 GATEHALL LN
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2720
Mailing Address - Country:US
Mailing Address - Phone:314-406-3843
Mailing Address - Fax:
Practice Address - Street 1:501 GATEHALL LN
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2720
Practice Address - Country:US
Practice Address - Phone:314-406-3843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004309224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant