Shannon Forman

Primary specialty

Occupational TherapistTaxonomy code 225X00000X

License

OTH-009316 Issued in AZ

Practice address

7654 N 19TH Ave
Phoenix, AZ 85021-7025

Phone

(602) 771-5400

NPI assigned

Jun 13, 2021

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1623542400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1729036800000",
    "number": "1407424823",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1469 E DOUGLAS ST",
            "city": "CASA GRANDE",
            "state": "AZ",
            "postal_code": "851221745",
            "telephone_number": "516-398-7478"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7654 N 19TH AVE",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850217025",
            "telephone_number": "602-771-5400"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1469 E Douglas St",
            "address_purpose": "LOCATION",
            "city": "Casa Grande",
            "state": "AZ",
            "postal_code": "851221745",
            "country_code": "US",
            "telephone_number": "516-398-7478",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FORMAN",
        "first_name": "SHANNON",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2021-06-13",
        "last_updated": "2024-10-16",
        "certification_date": "2024-09-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225X00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist",
            "state": "AZ",
            "license": "OTH-009316",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Occupational Therapist in Phoenix, AZ
• Providers in Phoenix, AZ by specialty
• Occupational Therapist in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 16, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.