Provider Demographics
NPI:1144597113
Name:BARNES, SHANNON M (LMT)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:M
Last Name:BARNES
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 1:10001 SE SUNNYSIDE RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5746
Mailing Address - Country:US
Mailing Address - Phone:503-962-9016
Mailing Address - Fax:
Practice Address - Street 1:12445 SE WHITCOMB DR
Practice Address - Street 2:APT # 1
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6992
Practice Address - Country:US
Practice Address - Phone:503-962-9016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171W00000X171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1OtherLICENSE MASSAGE THERAPIST