Provider Demographics
NPI:1477190965
Name:GREGORY, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 E MASON ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-4521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:526 S CREYTS RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8263
Practice Address - Country:US
Practice Address - Phone:727-385-7609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011702225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty