MEDICARE: SHANNON RENEE DOLPHIN O.T.R.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	8134	CA

General Provider Information

NPI Number	:	1013100320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON RENEE DOLPHIN O.T.R.

Provider Business Mailing Address
First Line	:	7400 CENTER AVE
Second Line	:	SUITE 106
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3094
Country	:	US
Telephone Number	:	714-901-4200
Fax Number	:	714-903-9425

Provider Business Practice Location Address
First Line	:	5252 EL CAJON BLVD
Second Line	:	SUITE B
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-4710
Country	:	US
Telephone Number	:	714-901-4200
Fax Number	:	714-903-9425

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2007
Last Update Date	:	08/20/2007

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