Provider Demographics
NPI:1083966600
Name:MITTS, SHANNON MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MITTS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:ROBERTS-HOLMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1624 US HIGHWAY 395 N
Mailing Address - Street 2:SUITE #1
Mailing Address - City:MINDEN
Mailing Address - State:NV
Mailing Address - Zip Code:89423-4326
Mailing Address - Country:US
Mailing Address - Phone:541-324-0499
Mailing Address - Fax:
Practice Address - Street 1:1624 US HIGHWAY 395 N
Practice Address - Street 2:SUITE #1
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423-4326
Practice Address - Country:US
Practice Address - Phone:541-324-0499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5848225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist