MEDICARE: MR. SHANE KENNETH MCCORMICK OTR/L

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	OT-1386	WY

General Provider Information

NPI Number	:	1295071611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHANE KENNETH MCCORMICK OTR/L

Provider Business Mailing Address
First Line	:	555 SAINT JOSEPHS BLVD
Second Line	:
City	:	ELMIRA
State	:	NY
Zip	:	14901-3223
Country	:	US
Telephone Number	:	607-733-6541
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 E BROADWAY AVE
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8636
Country	:	US
Telephone Number	:	307-734-2877
Fax Number	:	307-734-2827

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

Provider Enumeration Date	:	12/13/2012
Last Update Date	:	07/01/2020

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