=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891023511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON PATRICIA GATEWOOD OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2009
-----------------------------------------------------
Last Update Date | 11/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 W WELLS ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53233-2720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-937-2049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 355 E MONTANA ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53207-2017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-744-0964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 4682026
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------