Healthcare Provider Details

I. General information

NPI: 1114271715
Provider Name (Legal Business Name): SHANNON CLEAR PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2012
Last Update Date: 11/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5435 KENWOOD RD # 45227
CINCINNATI OH
45227-1328
US

IV. Provider business mailing address

4444 ASPEN DR
LIBERTY TWP OH
45011-5210
US

V. Phone/Fax

Practice location:
  • Phone: 513-271-1370
  • Fax:
Mailing address:
  • Phone: 513-364-8499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number07651
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: