Provider Demographics
NPI:1174892434
Name:SMITH, SHANNON DUNN (OTR/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DUNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 WINDING CREEK DR SW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-8616
Mailing Address - Country:US
Mailing Address - Phone:910-238-0447
Mailing Address - Fax:
Practice Address - Street 1:1705 TARBORO ST SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3428
Practice Address - Country:US
Practice Address - Phone:252-399-8998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5210225XR0403X, 225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility