Provider Demographics
NPI:1659070423
Name:KEITH, SHANNON DANAE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DANAE
Last Name:KEITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3603 BEECH HILL DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77388-5766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:146 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:BOURNE
Practice Address - State:MA
Practice Address - Zip Code:02532-3902
Practice Address - Country:US
Practice Address - Phone:562-822-9924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1371767225100000X
MEPT6507225100000X
CA301659225100000X
MA27234225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist