Healthcare Provider Details

I. General information

NPI: 1285226761
Provider Name (Legal Business Name): SHANNON BAYARD OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2021
Last Update Date: 02/06/2021
Certification Date: 02/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 RIVER AVE STE 201
LAKEWOOD NJ
08701-5675
US

IV. Provider business mailing address

4 ROCHELLE DR
HAZLET NJ
07730-2131
US

V. Phone/Fax

Practice location:
  • Phone: 732-833-3723
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR00939400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: