Provider Demographics
NPI:1497844732
Name:STEVENS, SHANNON MARIE (M S P T)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:M S P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 E FLORIDA ST/PO BX1518
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-5310
Mailing Address - Country:US
Mailing Address - Phone:505-546-2555
Mailing Address - Fax:505-546-2725
Practice Address - Street 1:722 E FLORIDA ST/PO BX1518
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-5310
Practice Address - Country:US
Practice Address - Phone:505-546-2555
Practice Address - Fax:505-546-2725
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM23693OtherLOVELACE
NM73559OtherPRESBYTERIAN
NMNM01Q136OtherBLUE CROSS BLUE SHIELD
NM57831271Medicaid
NMP00079902Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NM97005Medicare UPIN