=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013100320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON RENEE DOLPHIN O.T.R.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2007
-----------------------------------------------------
Last Update Date | 08/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5252 EL CAJON BLVD SUITE B
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92115-4710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-901-4200
-----------------------------------------------------
Fax | 714-903-9425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7400 CENTER AVE SUITE 106
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92647-3094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-901-4200
-----------------------------------------------------
Fax | 714-903-9425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 8134
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------