=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407518616
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON ROSE WAGNER OTD, OTR/L, CCTP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2021
-----------------------------------------------------
Last Update Date | 10/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23286 SW CINNAMON HILL PL
-----------------------------------------------------
City | SHERWOOD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97140-8927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-888-6993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1289
-----------------------------------------------------
City | SHERWOOD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97140-1289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XE0001X
-----------------------------------------------------
Taxonomy Name | Environmental Modification Occupational Therapist
-----------------------------------------------------
License Number | 350329
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Occupational Therapist
-----------------------------------------------------
License Number | 350329
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 350329
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------