Provider Demographics
NPI:1285784819
Name:ALEXANDER, SHANNON WILLIAMS (OTR L)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:WILLIAMS
Last Name:ALEXANDER
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:1275 HIGHWAY 54 W
Practice Address - Street 2:STE 200
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4549
Practice Address - Country:US
Practice Address - Phone:770-460-8609
Practice Address - Fax:770-460-8629
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT000918225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q53805Medicare UPIN
67BBMVMedicare ID - Type Unspecified
GA511I670016Medicare PIN