Provider Demographics
NPI:1497917819
Name:GOLDSBERRY, SHANNON SUE (LMP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SUE
Last Name:GOLDSBERRY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7010 27TH ST W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-5215
Mailing Address - Country:US
Mailing Address - Phone:253-534-8102
Mailing Address - Fax:253-565-3346
Practice Address - Street 1:7010 27TH ST W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-5215
Practice Address - Country:US
Practice Address - Phone:253-534-8102
Practice Address - Fax:253-565-3346
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010503172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0182749OtherWASHINGTON STATE DEPARTMENT OF LABOR AND INDUSTRIES