Provider Demographics
NPI:1407291677
Name:STUCKEY, SHANNON CULLERTON (OTR/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:CULLERTON
Last Name:STUCKEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:CULLERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:639 STRUCK STREET
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1383
Mailing Address - Country:US
Mailing Address - Phone:608-234-5990
Mailing Address - Fax:608-819-6825
Practice Address - Street 1:639 STRUCK STREET
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1383
Practice Address - Country:US
Practice Address - Phone:608-234-5990
Practice Address - Fax:608-819-6825
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7195-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist