Provider Demographics
NPI:1679155683
Name:SHANNON, LORETTA MAREE (OTR/L)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:MAREE
Last Name:SHANNON
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 1:1560 FLAIR ENCINITAS DR
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2943
Mailing Address - Country:US
Mailing Address - Phone:760-473-1776
Mailing Address - Fax:
Practice Address - Street 1:7220 AVENIDA ENCINAS STE 120
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-4660
Practice Address - Country:US
Practice Address - Phone:760-603-9457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA803225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist