Provider Demographics
NPI:1295850956
Name:HARRIS, SHANNON LOREN (PTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LOREN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LOREN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10202 CHASE COMMONS DR
Mailing Address - Street 2:APT. 305
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-4615
Mailing Address - Country:US
Mailing Address - Phone:240-273-2570
Mailing Address - Fax:
Practice Address - Street 1:8111 TIS WELL DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3211
Practice Address - Country:US
Practice Address - Phone:703-360-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602386225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant