MEDICARE: SHANNON TEADT COTA/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	224Z00000X	Occupational Therapy Assistant	5202007819	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5202007819	OTHER	MI	OCCUPATIONAL THERAPY ASSISTANT LICENSE

General Provider Information

NPI Number	:	1770084550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON TEADT COTA/L

Provider Business Mailing Address
First Line	:	269 N MATTESON LAKE RD
Second Line	:
City	:	BRONSON
State	:	MI
Zip	:	49028-9313
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1150 MICHIGAN AVE E
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49014-6113
Country	:	US
Telephone Number	:	269-962-5458
Fax Number	:

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

Provider Enumeration Date	:	02/26/2018
Last Update Date	:	02/26/2018

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Directions to “ SHANNON TEADT COTA/L” Practice Location

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