MEDICARE: MRS. SHANNON LEA DAVIS 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	5201000872	MI

General Provider Information

NPI Number	:	1538485982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANNON LEA DAVIS OTR/L

Provider Business Mailing Address
First Line	:	1181 FOREST BAY DR
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48328-4289
Country	:	US
Telephone Number	:	248-682-1169
Fax Number	:

Provider Business Practice Location Address
First Line	:	1181 FOREST BAY DR
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48328-4289
Country	:	US
Telephone Number	:	248-682-1169
Fax Number	:

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

Provider Enumeration Date	:	04/09/2010
Last Update Date	:	04/09/2010

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