Provider Demographics
NPI:1578232419
Name:BRANCH, SHANLEY (MT)
Entity Type:Individual
Prefix:
First Name:SHANLEY
Middle Name:
Last Name:BRANCH
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2104
Mailing Address - Country:US
Mailing Address - Phone:315-207-2222
Mailing Address - Fax:315-343-6923
Practice Address - Street 1:127 E 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2104
Practice Address - Country:US
Practice Address - Phone:315-207-2222
Practice Address - Fax:315-343-6923
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028593225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist