Healthcare Provider Details

I. General information

NPI: 1720134075
Provider Name (Legal Business Name): SHANA LYN NIELSEN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 BROADWAY
SEATTLE WA
98122-4379
US

IV. Provider business mailing address

2806 NW 59TH ST
SEATTLE WA
98107-2506
US

V. Phone/Fax

Practice location:
  • Phone: 206-386-2803
  • Fax: 206-386-6657
Mailing address:
  • Phone: 206-386-2803
  • Fax: 206-386-6657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT00002458
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: