Provider Demographics
NPI:1043603772
Name:MIDDLETON, SHANNON (LMP, CCTW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:LMP, CCTW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9410 7TH AVE SE
Mailing Address - Street 2:A10
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3702
Mailing Address - Country:US
Mailing Address - Phone:425-737-5509
Mailing Address - Fax:
Practice Address - Street 1:9410 7TH AVE SE
Practice Address - Street 2:A10
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3702
Practice Address - Country:US
Practice Address - Phone:425-737-5509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0023719172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist