Provider Demographics
NPI:1366757619
Name:WYLIE, SHANNON ELIZABETH (OTR/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:WYLIE
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 1:2037 PEAR TREE CT
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2111
Mailing Address - Country:US
Mailing Address - Phone:573-690-4963
Mailing Address - Fax:
Practice Address - Street 1:300 FLOYD DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-3960
Practice Address - Country:US
Practice Address - Phone:573-472-0397
Practice Address - Fax:573-472-0409
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010024922225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist