Provider Demographics
NPI:1770908741
Name:BERTSCH, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BERTSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 JACKSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-3814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:902 JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-3814
Practice Address - Country:US
Practice Address - Phone:609-239-3845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00639900225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist