MEDICARE: SHANNON WALTER OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	5201007411	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5201007411	OTHER	MI	STATE LICENSE

General Provider Information

NPI Number	:	1063551729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON WALTER OTR

Provider Business Mailing Address
First Line	:	1311 MAMARONECK AVE STE 140
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10605-5224
Country	:	US
Telephone Number	:	914-294-4050
Fax Number	:

Provider Business Practice Location Address
First Line	:	8542 W GRAND RIVER AVE
Second Line	:
City	:	BRIGHTON
State	:	MI
Zip	:	48116-2326
Country	:	US
Telephone Number	:	734-449-4649
Fax Number	:	734-449-4669

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	06/22/2023

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