Provider Demographics
NPI:1912918020
Name:MARTIN, SHANNON E (OT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARTIN
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1100 BLYTHE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5814
Mailing Address - Country:US
Mailing Address - Phone:704-355-4300
Mailing Address - Fax:704-355-4231
Practice Address - Street 1:1100 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5814
Practice Address - Country:US
Practice Address - Phone:704-355-4300
Practice Address - Fax:704-355-4231
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5571225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist