Provider Demographics
NPI:1447066105
Name:JOHN, SHANICE (OTR/L)
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:JOHN
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 1:1200 E 53RD ST APT 7K
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2342
Mailing Address - Country:US
Mailing Address - Phone:347-761-1187
Mailing Address - Fax:
Practice Address - Street 1:1200 E 53RD ST APT 7K
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2342
Practice Address - Country:US
Practice Address - Phone:347-761-1187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-07
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029697225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist