Healthcare Provider Details

I. General information

NPI: 1700552601
Provider Name (Legal Business Name): SHANA BOYLE OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 W HORIZON RIDGE PKWY STE 320
HENDERSON NV
89052-4395
US

IV. Provider business mailing address

8025 W RUSSELL RD APT 2077
LAS VEGAS NV
89113-1578
US

V. Phone/Fax

Practice location:
  • Phone: 702-564-4116
  • Fax:
Mailing address:
  • Phone: 630-536-6319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT-2814
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2918
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: