Provider Demographics
NPI:1083370183
Name:MOORE, SHANNAN DAYE (LMT)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:DAYE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 W 15TH ST STE 302A
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-7715
Mailing Address - Country:US
Mailing Address - Phone:469-666-4415
Mailing Address - Fax:
Practice Address - Street 1:3700 W 15TH ST STE 302A
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7715
Practice Address - Country:US
Practice Address - Phone:469-666-4415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2023-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT135376225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist