Healthcare Provider Details

I. General information

NPI: 1164935128
Provider Name (Legal Business Name): SHANNON RAY MCALLISTER OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7770 BURR ST
SCHERERVILLE IN
46375-3400
US

IV. Provider business mailing address

633 FILLMORE AVE
DYER IN
46311-1136
US

V. Phone/Fax

Practice location:
  • Phone: 219-322-8855
  • Fax:
Mailing address:
  • Phone: 219-616-0414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31005972A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: