Provider Demographics
NPI:1558131664
Name:SHANNON, ALYSON (LMT)
Entity Type:Individual
Prefix:
First Name:ALYSON
Middle Name:
Last Name:SHANNON
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 1:1023 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2793
Mailing Address - Country:US
Mailing Address - Phone:207-773-5778
Mailing Address - Fax:207-773-5773
Practice Address - Street 1:1023 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2793
Practice Address - Country:US
Practice Address - Phone:207-773-5778
Practice Address - Fax:207-773-5773
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT7596225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist