MEDICARE: SHANNON MARIE MULHOLLAN MOT/OTR

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	109602	TX

General Provider Information

NPI Number	:	1720710379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON MARIE MULHOLLAN MOT/OTR

Provider Business Mailing Address
First Line	:	1301 BELLE PL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-3360
Country	:	US
Telephone Number	:	817-368-2629
Fax Number	:

Provider Business Practice Location Address
First Line	:	3141 DALHART DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-2663
Country	:	US
Telephone Number	:	817-236-6116
Fax Number	:

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

Provider Enumeration Date	:	06/30/2022
Last Update Date	:	06/30/2022

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