Healthcare Provider Details

I. General information

NPI: 1063551729
Provider Name (Legal Business Name): SHANNON WALTER OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8542 W GRAND RIVER AVE
BRIGHTON MI
48116-2326
US

IV. Provider business mailing address

1311 MAMARONECK AVE STE 140
WHITE PLAINS NY
10605-5224
US

V. Phone/Fax

Practice location:
  • Phone: 734-449-4649
  • Fax: 734-449-4669
Mailing address:
  • Phone: 914-294-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5201007411
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: