Provider Demographics
NPI:1386717544
Name:MELLOTT, SHANNON LEIGH (OTA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEIGH
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:LEIGH
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA
Mailing Address - Street 1:5823 CHARLESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MERCERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17236-9442
Mailing Address - Country:US
Mailing Address - Phone:717-325-1018
Mailing Address - Fax:
Practice Address - Street 1:154 N ARTIZAN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:MD
Practice Address - Zip Code:21795-1104
Practice Address - Country:US
Practice Address - Phone:301-223-7971
Practice Address - Fax:301-223-7941
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA01493224Z00000X
PAOP005813224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant