Healthcare Provider Details

I. General information

NPI: 1861253296
Provider Name (Legal Business Name): SHANNEN D GONZALES MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 SALAZAR RD
TAOS NM
87571-8211
US

IV. Provider business mailing address

1030 SALAZAR RD
TAOS NM
87571-8211
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4274
  • Fax:
Mailing address:
  • Phone: 575-758-4274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-2023-0155
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: