Provider Demographics
NPI:1639994304
Name:KANNALLY, SHANNON MARIE (OTR)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:KANNALLY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:WRENTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02093-1075
Mailing Address - Country:US
Mailing Address - Phone:508-954-4612
Mailing Address - Fax:
Practice Address - Street 1:65 HOLBROOK ST STE 130
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:MA
Practice Address - Zip Code:02056-1849
Practice Address - Country:US
Practice Address - Phone:508-426-6491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15552225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist