Provider Demographics
NPI:1871900837
Name:VERNON, SHASTA (OTA)
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:
Last Name:VERNON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:SHASTA
Other - Middle Name:
Other - Last Name:DO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA
Mailing Address - Street 1:6361 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804
Practice Address - Country:US
Practice Address - Phone:419-841-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA.05564224Z00000X
OHOTA005564224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant