Provider Demographics
NPI:1982622791
Name:HACKETT, SHANNON (OTRL)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HACKETT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 12TH STREET N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-253-7257
Mailing Address - Fax:320-251-2938
Practice Address - Street 1:3701 12TH STREET N
Practice Address - Street 2:SUITE 100
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-253-7257
Practice Address - Fax:320-251-2938
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1044152OtherP ONE
6405829OtherMEDICA
182G6HAOtherBCBS
670000341OtherMETRAHEALTH MPIN
P00282811OtherRAILROAD MEDICARE
1044152OtherP ONE