Provider Demographics
NPI:1437394830
Name:OLIN, SHANNON MAKUEN (PT)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:MAKUEN
Last Name:OLIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 CENTRE ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2511
Mailing Address - Country:US
Mailing Address - Phone:617-512-4197
Mailing Address - Fax:671-477-4659
Practice Address - Street 1:670 CENTRE ST
Practice Address - Street 2:SUITE #1
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2511
Practice Address - Country:US
Practice Address - Phone:617-512-4197
Practice Address - Fax:671-477-4659
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-13
Last Update Date:2008-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7263225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist