Basic Information
| Provider Information | |||||||||
| NPI: | 1720415029 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SHANNON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 HOWARD DR | ||||||||
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| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400658138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026331007 | ||||||||
| FaxNumber: | 5028051511 | ||||||||
| Practice Location | |||||||||
| Address1: | 4121 SHELBYVILLE RD STE 7 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402073205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028931380 | ||||||||
| FaxNumber: | 5028931773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2013 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31005496A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 5201008405 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | R5721 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.