Provider Demographics
NPI:1578857363
Name:BROWN, SHANNON LANE (COTA)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:LANE
Last Name:BROWN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 COUNTY ROAD 1721
Mailing Address - Street 2:
Mailing Address - City:BAY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39422-9804
Mailing Address - Country:US
Mailing Address - Phone:601-467-3476
Mailing Address - Fax:
Practice Address - Street 1:43 COUNTY ROAD 1721
Practice Address - Street 2:
Practice Address - City:BAY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39422-9804
Practice Address - Country:US
Practice Address - Phone:601-467-3476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2354224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant