MEDICARE: SUSAN SHERSHOW OT

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	66	ME

General Provider Information

NPI Number	:	1750698346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN SHERSHOW OT

Provider Business Mailing Address
First Line	:	6 MORTLAND RD
Second Line	:	RSU20 SPECIAL SERVICES OFFICE
City	:	SEARSPORT
State	:	ME
Zip	:	04974-3332
Country	:	US
Telephone Number	:	207-548-6643
Fax Number	:

Provider Business Practice Location Address
First Line	:	56 BAYSIDE RD
Second Line	:	EDNA DRINKWATER SCHOOL
City	:	NORTHPORT
State	:	ME
Zip	:	04849-4435
Country	:	US
Telephone Number	:	207-338-3430
Fax Number	:

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

Provider Enumeration Date	:	09/03/2010
Last Update Date	:	09/03/2010

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