Provider Demographics
NPI:1518260405
Name:SHANNON LOGAN HEALY PT
Entity Type:Organization
Organization Name:SHANNON LOGAN HEALY PT
Other - Org Name:SHANNON LOGAN HEALY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:HEALY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:310-650-3854
Mailing Address - Street 1:1033 12TH STREET
Mailing Address - Street 2:102
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-650-3854
Mailing Address - Fax:
Practice Address - Street 1:1033 12TH STREET
Practice Address - Street 2:102
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-650-3854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT35550OtherCA LICENSE