=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669947982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON M BODDY OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2018
-----------------------------------------------------
Last Update Date | 07/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2540 CARMICHAEL WAY
-----------------------------------------------------
City | CARMICHAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95608-5314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-482-0465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 934 OH-28
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Occupational Therapist
-----------------------------------------------------
License Number | 12826
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 19286
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------