Provider Demographics
NPI:1992270003
Name:WIESE, SHANNON MCGARRY (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MCGARRY
Last Name:WIESE
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15517 27TH DR SE
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-4845
Mailing Address - Country:US
Mailing Address - Phone:425-308-2509
Mailing Address - Fax:
Practice Address - Street 1:1800 INDEX AVE NE
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-2314
Practice Address - Country:US
Practice Address - Phone:425-224-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60821432225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist