MEDICARE: SHELBY KNOTT

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	224Z00000X	Occupational Therapy Assistant	OTA2490	CA

General Provider Information

NPI Number	:	1619359460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY KNOTT

Provider Business Mailing Address
First Line	:	3940 GRESHAM ST UNIT 423
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-5810
Country	:	US
Telephone Number	:	619-733-0812
Fax Number	:

Provider Business Practice Location Address
First Line	:	3940 GRESHAM ST UNIT 423
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-5810
Country	:	US
Telephone Number	:	619-733-0812
Fax Number	:

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

Provider Enumeration Date	:	06/28/2015
Last Update Date	:	03/28/2016

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