Provider Demographics
NPI:1316101280
Name:MICHENER, SHANNON KUMARI (MS, OTR)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KUMARI
Last Name:MICHENER
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 DOVER CT
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8822
Mailing Address - Country:US
Mailing Address - Phone:765-438-7225
Mailing Address - Fax:
Practice Address - Street 1:1001 N GRANT ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1944
Practice Address - Country:US
Practice Address - Phone:765-482-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003383A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist