Provider Demographics
NPI:1962686618
Name:MAIN, SHARA LEE M (OT)
Entity type:Individual
Prefix:
First Name:SHARA LEE
Middle Name:M
Last Name:MAIN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 CLEMENT ST
Mailing Address - Street 2:ATTN: OCCUPATIONAL THERAPY GB -27
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-1545
Mailing Address - Country:US
Mailing Address - Phone:415-221-4810
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST
Practice Address - Street 2:ATTN: OCCUPATIONAL THERAPY GB-27
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1545
Practice Address - Country:US
Practice Address - Phone:415-221-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPENDING225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000663190OtherBCBS PIN
MT000663190OtherBCBS PIN
MT1153260003Medicare PIN
MT011001263Medicare PIN