Provider Demographics
NPI:1528740230
Name:CAVANAUGH, SHANNON NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 DANIEL BOONE RD
Mailing Address - Street 2:
Mailing Address - City:NORTONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42442-9743
Mailing Address - Country:US
Mailing Address - Phone:270-339-2889
Mailing Address - Fax:
Practice Address - Street 1:213 WATER ST
Practice Address - Street 2:
Practice Address - City:DAWSON SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42408-1727
Practice Address - Country:US
Practice Address - Phone:270-797-2025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant