Provider Demographics
NPI:1679162531
Name:PETERS, SHANEL SANDRA
Entity type:Individual
Prefix:
First Name:SHANEL
Middle Name:SANDRA
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANEL
Other - Middle Name:SANDRA
Other - Last Name:BOSANIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:825 RUNYAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405
Mailing Address - Country:US
Mailing Address - Phone:423-875-6723
Mailing Address - Fax:
Practice Address - Street 1:825 RUNYAN DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-1225
Practice Address - Country:US
Practice Address - Phone:423-875-6723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5233225X00000X
TN6576225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist