MEDICARE: SHANNON B TELLER

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	017144	NY

General Provider Information

NPI Number	:	1952672255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON B TELLER

Provider Business Mailing Address
First Line	:	873 56TH ST
Second Line	:	APARTMENT A
City	:	BROOKLYN
State	:	NY
Zip	:	11220-3615
Country	:	US
Telephone Number	:	347-733-9995
Fax Number	:

Provider Business Practice Location Address
First Line	:	3806 FLATLANDS AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-3433
Country	:	US
Telephone Number	:	917-754-6634
Fax Number	:	718-576-1801

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

Provider Enumeration Date	:	01/18/2012
Last Update Date	:	11/13/2012

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Directions to “ SHANNON B TELLER ” Practice Location

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