Provider Demographics
NPI:1487963906
Name:GRADY-TARENTINO, SHANNON (OTR/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GRADY-TARENTINO
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 1:50 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-2530
Mailing Address - Country:US
Mailing Address - Phone:908-966-6994
Mailing Address - Fax:
Practice Address - Street 1:40 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3312
Practice Address - Country:US
Practice Address - Phone:718-370-7529
Practice Address - Fax:718-370-7551
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009275-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics