Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | OP008915 | PA |
NPI | 1023501335 |
---|---|
Provider Name | Shana Coyette Bundrage |
First Address | Philadelphia, PA 19119-3931 |
Second Address | Meadowbrook, PA 19046-8098 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2018 |
Last Update Date | 11/06/2018 |