Provider Demographics
NPI:1619290855
Name:REISSMAN, SHANNON MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:REISSMAN
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 1:2321 49TH ST S
Mailing Address - Street 2:SUITE C
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-5118
Mailing Address - Country:US
Mailing Address - Phone:727-391-1000
Mailing Address - Fax:
Practice Address - Street 1:2321 49TH ST S
Practice Address - Street 2:SUITE C
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-5118
Practice Address - Country:US
Practice Address - Phone:727-391-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA22783225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist