Provider Demographics
NPI:1508393380
Name:MARTIN, SHANNAW DALE (LMT)
Entity Type:Individual
Prefix:
First Name:SHANNAW
Middle Name:DALE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 362
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:CO
Mailing Address - Zip Code:80024-0362
Mailing Address - Country:US
Mailing Address - Phone:720-448-8585
Mailing Address - Fax:
Practice Address - Street 1:8093 RALEIGH ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-4313
Practice Address - Country:US
Practice Address - Phone:720-448-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0003584225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist