Provider Demographics
NPI:1871767988
Name:RUZICKA, SHANNON RENAE (OTR/L)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENAE
Last Name:RUZICKA
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 1:50 TALL GRASS CIR
Mailing Address - Street 2:
Mailing Address - City:BENNET
Mailing Address - State:NE
Mailing Address - Zip Code:68317-2411
Mailing Address - Country:US
Mailing Address - Phone:402-310-9505
Mailing Address - Fax:
Practice Address - Street 1:50 TALL GRASS CIR
Practice Address - Street 2:
Practice Address - City:BENNET
Practice Address - State:NE
Practice Address - Zip Code:68317-2411
Practice Address - Country:US
Practice Address - Phone:402-310-9505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1246225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist