MEDICARE: SHANNON M HARDEGREE

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	225XP0200X	Pediatric Occupational Therapist		GA

General Provider Information

NPI Number	:	1598979221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON M HARDEGREE

Provider Business Mailing Address
First Line	:	809 EDEN ST
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-1571
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	705 17TH ST STE 208
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31901-3506
Country	:	US
Telephone Number	:	706-327-0189
Fax Number	:

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

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	07/08/2007

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Directions to “ SHANNON M HARDEGREE ” Practice Location

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