Provider Demographics
NPI:1194312728
Name:JOHNSON, SHANNON CHAUNTAY (COTA/L)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:CHAUNTAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:CHAUNTAY
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:279 S EAGLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5919
Mailing Address - Country:US
Mailing Address - Phone:859-948-2305
Mailing Address - Fax:
Practice Address - Street 1:200 MERIDIAN WAY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3331
Practice Address - Country:US
Practice Address - Phone:859-353-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175326224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant