Provider Demographics
NPI:1710722483
Name:WARE, SHANNON (COTA/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WARE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 SHETTERLY LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-2228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 ELMWOOD CIR
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-2428
Practice Address - Country:US
Practice Address - Phone:937-866-3814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
OH02850224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant